LIBRARY OF CONGRESS. 

eipp iojt^igjW^u. 



UNITED STATES OF AMEKIOA. 



PAIN 



IN ITS 

NEURO-PATHOLOGICAL, DIAGNOSTIC, MEDICO- 
LEGAL, AND NEURO-THERAPEUTIC 
RELATIONS. 

f / BY 

J. LBONAED COBNING, A.M., M.D., 

II 

CONSULTANT IN NERVOUS DISEASES TO ST. FRANCIS HOSPITAL, ST. MARY'S HOSPITAL, 

THE HACKENSACK HOSPITAL, ETC. ; FELLOW OF THE NEW YORK ACADEMY OF 
MEDICINE; MEMBER OF THE NEW YORK NEUROLOGICAL SOCIETY, THE MEDI- 
CAL SOCIETY OF THE COUNTY OF NEW YORK, AND THE MEDICAL SOCIETY 
OF THE STATE OF NEW YORK, ETC. 

AUTHOR OF "A TREATISE ON HEADACHE AND NEURALGIA," " BRAIN-EXHAUSTION, 
WITH SOME PRELIMINARY CONSIDERATIONS ON CEREBRAL DYNAMICS," "LOCAL 
ANESTHESIA," " A TREATISE ON HYSTERIA AND EPILEPSY," " BRAlN-REST : 
BEING A DISQUISITION ON THE CURATIVE PROPERTIES OF PRO- 
LONGED SLEEP," ETC. 



ILLUSTRATED. 



t 



^APR 3 18** 




PHILADELPHIA 



J. B. LIPPINCOTT COMPANY. /^ 




1894. 



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Copyright, 1894, 

BY 

J. B. Lippincott Company. 



Printed by J. B. Lippincott Company, Philadelphia. 



TO MY 
MATERNAL UNCLE, 

FREDERICK DEMING, 

AS A TOKEN OP ADMIKATION 
AND AFFECTION. 



PREFACE. 



11 Pains are the correlatives of actions injurious to the organism, 
while pleasures are the correlatives of actions conducive to its wel- 
fare." — Herbert Spencer, Principles of Psychology. 

11 The phenomena of feeling constitute the true basis of all that 
part of philosophy which at all involves the interest of man." — 
Lester F. "Ward, Dynamic Sociology. 

There is no department of neurology a knowledge 
of which is so essential to the physician as that 
which deals with pain. As an aid to diagnosis the 
importance of this symptom is unique; while to 
relieve it requires discernment and ingenuity of a 
high order. 

Nor is its ethical significance less apparent; for 
surely there is nothing in all the world so con- 
ducive to an active sympathy with mankind as the 
habitual relief of suffering. 

Since, during the past ten years, the author has 
devoted much time to the study of pain, he is led 
to hope that in presenting this volume he may be 
able to advance in some degree the cause of scien- 
tific medicine. 

53 West Thirty-eighth Street, New York. 
March 1, 1894. 

1* 6 



CONTENTS. 



PART I. 

PHYSIOLOGICAL, PATHOLOGICAL, AND CLINICAL. 



CHAPTER I. PAGE 

The Physiology of Pain— Conduction— Definition . . 11 

CHAPTER II. 

The Pathology of Pain — Neuritis, or Inflammation 
of the Neryes — Multiple Neuritis — Chronic Alco- 
holic Neuritis — Neuritis Consecutive to Influenza 
—The Neuritis of Leprosy— Beriberi 29 

CHAPTER III. 
Concerning Pains located in Definite Nerve-Areas 
— Neuralgia . 62 

CHAPTER IV. 
Pain associated with the Rheumatic and Gouty 
Diathesis 70 

7 



8 CONTENTS. 

CHAPTEK V. page 

Pains which have their Seat in the Structures con- 
tained within the Cavities of the Body — Intra- 
cranial Pains (Headache) — "Spinal" (Medullary) 
Pains— Abdominal and Thoracic (Visceral) Pains . 80 

CHAPTEE VI. 
The Diagnostic Value of Pain 92 

CHAPTER VII. 

The Clinical and Medico-Legal Significance of the 
Phenomena evoked by Pain — Objective Method of 
diagnosticating Pain 108 

CHAPTER VIII. 
The Medico-Legal Relations of Pain — Spinal Con- 
cussion 117 

CHAPTER IX. 
Of the Insomnia and Melancholia of Pain 128 



PART II. 

THE SPECIAL THERAPEUTICS OF PAIN. 



CHAPTER X. 

Concerning the Importance of Rest in the Treatment 
of the Nervous Symptoms engendered by Prolonged 
and Severe Pain 140 



CONTENTS. 9 

CHAPTEK XL PAGE 

Op Internal Eemedies which are either directly 
or indirectly Applicable in the Treatment op 
Pain 165 

CHAPTEK XII. 
Op other and More Kecent Eemedies which have 
been employed in the treatment of pain 189 

CHAPTEK XIII. 

Summary op other Important Facts Kelative to the 
Action of Remedies on the Nervous System .... 198 

CHAPTER XIY. 

On the Author's Methods of employing Remedies so 
as to Increase the Certainty and Duration of 
their Action on the Peripheral Nerves — Other 
Measures which have been proposed 206 

CHAPTER XV. 
Surgical Expedients 227 

CHAPTER XVI. 

Local Medication of the Spinal Cord and Cauda 
Equina, Author's Plan— Other Measures 241 

CHAPTER XVII. 

The Use of Compressed Air in conjunction with 
Remedies which tend to diminish the Acuity op 
Perception, Author's Plan. . 256 

CHAPTER XVIII. 

Reflex and Spurious or Imaginary Pains— Hypnotism 304 



10 CONTENTS. 

CHAPTER XIX. p AGE 

Concluding Observations on the Prevention of Re- 
lapse — The Prophylaxis of Pain 313 

CHAPTER XX. 
Supplementary Observations on Torture, or the In- 
fliction of Pain as a Judicial Punishment or for 
the Purpose of extorting a Confession of Guilt . 318 



PART L 

PHYSIOLOGICAL, PATHOLOGICAL, AND CLINICAL. 



CHAPTER L 

THE PHYSIOLOGY OF PAIN — CONDUCTION — DEFINITION. 

Definition of Pain. — Various attempts have been 
made to define pain. Cicero looked upon it as a 
disagreeable movement within the body, indepen- 
dent of the senses. According to others, it is a 
species of sensation which may emanate from both 
internal and external regions of the body, in which 
are distributed nerves, " whose office it is to transmit 
to the brain all impressions." Sauvage calls it a 
disagreeable perception, originating from any lesion 
of the nerve-fibres ; Gaubius regards it as a sensation 
which the mind "would rather not experience" (!); 
while Bilon is discontented with all definitions, 
and believes the word pain to be so universally de- 
scriptive in itself as to enable one to dispense with 

11 



12 PAIN. 

all definitions. 1 More recent authors have, never- 
theless, persisted in further attempts to define it. 
Thus Valentin 2 perceives in pain " sensory impres- 
sions which, on account of their too great intensity, 
become disagreeable;'' "Wundt 3 calls it "a feeling 
that accompanies all powerful or intense stimuli," 
while Eulenburg 4 defines it as " a gradual increase 
of the feeling that accompanies every sensory pro- 
cess." 

To my mind, the views of Erb 5 regarding the 
nature of pain are among the most comprehensive 
which have been recently expressed. " We hold," 
he says, " that every increase of ordinary sensory 
stimuli is capable of producing pain, as soon as it 
attains a certain intensity. Every excitation, the 
intensity of which exceeds certain limits, every 
molecular change of the centripetal series, induced 
by an abnormally strong stimulus, is perceived as 
pain. Very simple experiments, as, for example, 
pressure or temperature gradually increased till pain 

1 Dictionnaire des Sciences Medicales, vol. x. p. 179, Paris, 1814. 

2 Physiologische Pathologie der N erven, vol. i. p. 240. 

3 Lehrbuch der Physiologie des Menschen, p. 503, 1874. 

4 Functionelle Nervenkrankheiten, p. 31. Vide also Diseases of 
the Peripheral Cerebro-Spinal Nerves, by Wilhelm Heinrich Erb, 
Ziemssen's Cyclopaedia, vol. xi. p. 14. 

5 Op. et loc. cit. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 13 

is produced, show that, with very gradual increase 
in the strength of the stimulus, a limit is at length 
reached beyond which the excitory process is ac- 
companied by pain, yet no sharp line of demarca- 
tion can be traced denning the point at which the 
sensation of pressure or temperature ceases and the 
sensation of pain commences." 

Regarding, then, the phenomena concerned in 
their broadest aspect, I would define pain as the 
feeling (perception) evoked by over-stimulation of 
the nerves of special and common sensation. By 
over-stimulation is meant, of course, a degree of 
stimulation which exceeds the physiological limit. 

We have thus a clue to the genesis not only of 
those pains which originate in over-stimulation of 
the nerves of common sensation, with which we are 
most frequently called upon to deal, but of those 
likewise which have their origin in an exaggerated 
stimulation of the nerves of special sense ; for do we 
not know that intense light and loud inharmonious 
noises produce sensations which are described by 
those subjected to them as veritable pains ? 

In view of these facts, nothing can be more in- 
consistent — to give it no stronger name — than the 
attempts of those extremists whom Brown-Sequard 
has facetiously alluded to as the " cluster localizers" 
to ascribe the perception of pain to a limited area 

2 



14 PAIN. 

of the cortex. Clearly, a hypothetical spot of this 
kind could by no possibility serve as the rendezvous 
for the pain-concepts of both special and common 
sensation. 

Such a centralization of heterogeneous functions 
is physiologically, not to say anatomically, un- 
thinkable. 

From all this it is evident, then, that the modifi- 
cation engendered in the perceptive mechanisms of 
common and special sensation by excessive stimula- 
tion is the principal, if not the only, prerequisite to 
the development of pain. 

As regards those fine molecular perturbations 
originating in the nerve and transmitted thence to 
the sensorium, — perturbations which are evidently 
the ultimate and essential element of pain, — we are 
still, and doubtless are destined in future to remain, 
entirely in the dark. Although we are thus de- 
barred, on account of the crudity of our physiology, 
from penetrating the final mystery of pain, we are, 
nevertheless, enabled to adopt proper means for its 
arrest when once established. 

As the argument proceeds, we shall find that, in 
combating pain, we are compelled to invoke the 
aid of a wide range of agents ; and thus it happens 
that chemistry, thermo-dynamics, physics, and even 
surgery have all rendered important assistance. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 15 

Finally, we must not forget to mention a very 
recent theory regarding the mechanism underlying 
the pains occurring along the course of nerves. 
According to Prus, 1 who is the promulgator of this 
theory, there are filaments in the sheaths of nerve- 
trunks the irritation of which gives rise to the 
painful points found in neuralgic affections. These 
filaments, the presence of which was made known 
by careful microscopical examination, have received 
the somewhat ponderous appellation of nervi nervo- 
rum periphericorum. 

It is, of course, impossible at present to prophesy 
with any degree of certainty what part these struct- 
ures are destined to play in the physiology and 
pathology of the future. Perhaps autopsies con- 
ducted with a special view to further enlightenment 
on this point may afford assistance ; but it is hardly 
to be anticipated that we shall derive much help 
from experimentation. 

The Transmission of Painful Impressions from 
the Periphery to the Perceptive Mechanism. — The 
next question which naturally suggests itself is, 
how do painful impressions reach the higher centres 
of the brain ? or, in other words, along what paths 
do such impressions travel in their journey from 

1 Archives Slaves de Biologie ; also Brain, vol. x. p. 657. 



16 



PAIN. 



the periphery to the mechanism (" centre") of con- 
scious perception ? 

It is much to be regretted that only a partial 
answer can be given to this important question. 

About all we know of the matter is soon told. 
In the first place, as every one knows, the trans- 

FlG. 1. 




AN TER10RH0RH 



>stfl** *** 



mission of painful sensations from the periphery to 
the spinal cord is accomplished through the instru- 
mentality of the sensory nerves. The course pur- 
sued by such painful impressions through the cord 
is more obscure. Some physiologists believe that, 
after crossing to the opposite side of the cord, they 
are transmitted wholly through the gray substance ; 
others, again, assign special importance to the sen- 
sory conducting paths of the posterior columns; 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 17 



Fig. 2. 



while a third class of observers believe that sensa- 
tions of pain may be transmitted both through the 
gray substance and the white substance of the pos- 
terior and lateral columns. 

But while the direction pursued by the sensory 
pathway after crossing in the cord is not altogether 
clear, the decussation itself seems adequately demon- 
strated. Evidence of this intersection of the fibres 
is afforded by the fact 
that, when one lateral half 
of the cord is divided 
transversely by traumatism 
or disease, the parts below 
it on the same side are 
paralyzed, while sensation 
is lost in the corresponding 
parts on the opposite side. 
Thus it is that sensory 
fibres from the right half 
of the body cross the me- 
dian line and ascend in . 
the left half of the cord, 
while those from the left 
half of the body decussate and pass upward on the 
right side of the cord. The decussation of the sen- 
sory fibres in the cord is indicated in the diagrams, — 
Fig. 1, transverse, and Fig. 2, longitudinal, section. 
b 2* 




18 PAIN. 

Our knowledge of the route pursued by the sen- 
sory fibres through the medulla oblongata and the 
pons is quite indefinite, and the same may be said 
of the relation which these tracts sustain to the 
gray matter of those regions. From the data 
available, it would seem, however, that sensation is 
transmitted onward through the tegmentum to the 
hindermost portion of the posterior limb of the 
internal capsule, and thence, by way of the corona 
radiata, to the cerebral cortex. At its point of 
transit through the internal capsule the sensory 
pathway seems to lie in close proximity to the fibres 
destined for the conduction of the impressions of 
the special senses. 

The Sensory Regions of the Cortex. — The evi- 
dence that the nerves of special sense are con- 
nected with definite areas of the cerebrum may 
be thus summarized : 

Certain fibres of the olfactory tract have been 
traced to the hippocampal gyrus in the temporal 
lobe; and it has been observed that keenness of 
the sense of smell is materially lessened after lesion 
of the hippocampus. The so-called " taste centre" 
has been located in the temporal lobe in the vicinity 
of that of smell ; but the .evidence in favor of as- 
signing it to this locality is inconclusive. Nor is 
the location of the auditory centre altogether cer- 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 19 

tain, in spite of the attempts to associate it with 
the superior temporal convolution. Some of the 
phenomena bearing on the question are, however, 
sufficiently interesting to deserve mention. 

In the first place, it has been observed that, after 
destruction of the internal ear, the median corpus 
geniculatum and posterior corpus quadrigeminum 
atrophy ; and, secondly, atrophy of the nuclei may 
be induced by destroying the superior temporal 
convolution. Additional experiments and patho- 
logical investigations are required to establish this 
somewhat complicated connection. 

The cortical area concerned in visual perception — 
the so-called optic centre — is much more definitely 
located than any of those previously considered. 
It seems, indeed, exceedingly probable, to say the 
least, that that portion of the occipital lobe called 
the cuneus is intimately associated with visual per- 
ception ; for when, for example, the right occipital 
lobe is removed or rendered inoperative by disease, 
left hemiopia results, and vice versa, while the ob- 
literation of both occipital lobes gives rise to total 
blindness. 

There are other collateral facts bearing on the 
question, such as the secondary atrophy of the 
pulvinar of the thalamus, the lateral corpus geni- 
culatum, and the median corpus quadrigeminum 



20 



PAIN. 



after extirpation of the occipital cortex, but the 
essentially practical scope of this work precludes 
their consideration. 

An immense amount of discussion has been lav- 
ished on the question as to what portions of the 
cerebral cortex are associated with cutaneous sen- 
sation. In my opinion, the evidence at present 
available — though certainly to some extent con- 

Fig. 3. 




flicting — goes to show that the so-called "sensory 
centres" are distributed throughout the "motor 
area," if indeed they do not extend beyond it. 

It is a well-known fact that irritation of the sen- 
sory nerves of the skin may produce several kinds 
of sensations ; or what amounts to the same thing, 
these nerves are endowed with different kinds of 
sensibility. 



21 

Thus, we have a sense of locality, tactile sensi- 
bility, sense of temperature, " sense of pain," and 
sense of pressure, according to the mode of action 
of the peripheral irritant. 

In certain diseases of the nervous system some or 
all of these powers of discrimination may be im- 

Fig. 4. 




paired or lost; so that from a diagnostic point of 
view the investigation of cutaneous sensibility is 
a matter of importance. Whether — as has been 
alleged and as some facts tend to show — each va- 
riety of cutaneous sensibility is provided with a 



22 PAIN. 

separate and distinct pathway is, however, still an 
open question. 

The regions previously discussed are shown in 
the annexed diagrams. The hypothetical areas 
(" centres") of vision, smell, and taste, as viewed 
from the mesial aspect of the brain, are shown in 
Fig. 3, while the sensori-motor region and the lo- 
cality supposed to be associated with hearing are 
indicated in Fig. 4, representing the right cerebral 
hemisphere. 

Identity of the Processes in Motor and Sensory 
Nerves. — It has often been asked, as a matter of 
theoretic interest, whether the processes accom- 
plished in a motor nerve differ radically from those 
occurring in a sensory nerve. On this point, Rad- 
clilfe, in concluding an elaborate argument, observes, 
" that there is reason to believe that there is no 
essential difference between the action which issues 
in sensation and the action which issues in mus- 
cular contraction." As a corollary to this proposi- 
tion, he adds: "that the production of sensation 
and the production of muscular contraction only 
differ in this, — that the electrical discharge, analo- 
gous to that of the torpedo, which is developed in 
and near the nerve in the state of nervous action, 
happens to tell upon sensorial ganglionic cells in 
the one case, and upon muscular fibres in the other." 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 23 

Of course to speak of the electricity evolved 
during the action of a nerve as though it were 
the nerve-force concerned in the production of 
sensation or motion is a mistake. In other re- 
spects, the figure is an apt one. 

It may be of interest, in this connection, to con- 
sider the experiments which have led Radcliffe and 
others to these conclusions. Undoubtedly the re- 
searches of Du Bois Reymond and Matteucci have 
had a powerful influence in shaping opinion. 

The principal experiment of Du Bois Eeymond 
consists in pouring hot water upon the leg of a 
frog, the nerve of the same being connected with 
a galvanometer. When this is done, the galvanom- 
eter shows a cessation of the electrical current, — a 
phenomenon which is observed almost as soon as 
the water touches the integument. This observa- 
tion in conjunction with the well-known fact that 
there is also a decrease, amounting sometimes to 
almost entire absence of " natural electricity," dur- 
ing the action of motor nerves, led Du Bois Rey- 
mond to the inference that in sensory as well as 
motor nerves there is a loss of electricity when the 
nerves pass from rest into a state of action. 

Matteucci's experiment, performed upon a rabbit, 
consisted in dissecting out the upper portion of the 
sciatic nerve and in irritating it with the galvanic 



24 PAIN. 

current. When the current was closed the animal 
screamed loudly, but when it was opened there was 
no sign of pain. 

The resemblance of the phenomena evoked by 
the galvanic current in sensitive and motor nerves 
has led to the inference that the change in a sen- 
sory nerve when sensation is produced by the 
action of voltaic electricity, and the change in a 
motor nerve when muscular contraction is produced 
by the same means, are, as Radcliffe puts it, exact 
equivalents. 

Such, then, are the principal facts which have 
been assumed to prove the identity of the processes 
underlying the actions of motor and sensory nerves. 
While, however, the relation of the two kinds of 
nerves to the galvanic current points to the truth 
of this proposition, it is, of course, self-evident that 
the final result of the action differs radically in each 
kind of nerve. In the case of the motor nerve, 
action results in contractions, due to the excitation 
of the contractile substance of the muscle ; in the 
case of the sensory nerve, on the other hand, action 
is translated into perception, through the instrumen- 
tality of the central ganglionic apparatus in the 
cortex. 

So much for the fundamental features of the 
argument. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 25 

Concerning the Correct and Erroneous Refer- 
ence of Painful Sensations. — While all are aware 
of that remarkable attribute of the perceptive mech- 
anism which usually enables the individual to refer 
with great exactness both agreeable and disagree- 
able sensations to their point of origin at the periph- 
ery, few comparatively have given thought to the 
anatomical arrangement underlying this phenome- 
non; and fewer still are able to account for those 
apparent paradoxes, which obscure the physiology 
involved and tend to discredit its application in the 
clinic. Hence we shall not, I believe, misuse our 
time if we devote a few paragraphs to a review of 
the more important points connected with referred 
sensations. 

In the first place, then, it must be remembered 
that a sensory nerve supplies a certain area of the 
body and transmits to the brain only such impres- 
sions as emanate from that area. In other words, 
there is no physiological anastomosis, however much 
the fibres may interlace or run together. To prove 
this, it is only necessary to divide a sensory nerve 
and irritate its distal end, when we find that 
no sensation is perceived, thus demonstrating that 
there is no collateral communication whatsoever. 
As a matter of course, irritation of the proximal 
or central portion of the nerve — that part which 
B 3 



26 PAIN. 

is connected with the nerve-centres — gives rise to 
distinct sensation. 

In the same way, if we divide the spinal cord of 
an animal transversely, so as to sever the sensory 
conducting paths, and irritate the nerves which join 
the cord below the incision, no sensation will be 
perceived; but if we stimulate the nerves which 
enter the cord above the incision, we shall have 
every evidence that the sensation has been per- 
ceived. Precisely the same sort of phenomena may 
be observed in human beings who by reason of 
injury or disease have suffered a solution of the 
sensory conducting paths of the cord. 

Another important fact is, that an impression made 
upon any point in the course of a sensory nerve may 
be perceived by the mind as though it were made 
not only upon the point in question, but also upon 
the part to which the fibres of the nerve are dis- 
tributed. "We have, therefore, under such circum- 
stances, practically the same effect as if the irritation 
were applied to the regions supplied by the branches 
of the nerve. 

An explanation is thus afforded of the fact that 
when the sensibility of a part is abolished by com- 
pression or division of the nerve which supplies it, 
irritation of the central portion may still give rise 
to sensations which are felt as though they emanated 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 27 

from the parts below the point of interruption, — i.e., 
from the parts to which the peripheral terminations of 
the nerve are distributed. Thus, when a nerve is di- 
vided for the cure of an intractable form of neuralgia, 
it sometimes happens that pain still persists. This is 
undoubtedly due to the fact that the division of the 
nerve has not been made near enough to the nerve- 
centres to include the entire affected portion, and 
hence the continued irritation of the central portion 
causes pain, which, in accordance with the law under 
consideration, is felt as though it emanated from the 
peripheral parts of the nerve. Another illustration 
of the same thing is found in those paralyses in 
which the limbs are quite insensible to such external 
stimuli as pricking, pinching, and burning, and yet 
are believed by the patient to be the seat of severe 
pain. Still another example of erroneously referred 
pains is seen in persons who have suffered am- 
putation of a limb. When the divided nerves of 
the stump are inflamed, or otherwise irritated, noth- 
ing is more common than to hear the subject com- 
plain that he experiences pain which appears to be 
located in the part of the limb which has been 
removed. 

Such facts as these might, on a superficial exami- 
nation, lead one to suppose that there was little or 
no benefit to be anticipated from local therapeutic 



28 PAIN. 

measures addressed to the affected nerve itself in 
cases of pain. It must be remembered, however, 
that by the aid of chemicals we are in many cases 
able not only to temporarily cut off the peripheral 
portion of an affected nerve from its central con- 
nections, but also to modify the abnormal condition 
of the nerve itself, thus accomplishing an abolition 
of pain which is often permanent. From this it 
follows that we can deal much more effectively with 
circumscribed neuritis and congestion by the aid of 
local remedies than with diffuse inflammation of 
the nerves, which can only be reached by remedies 
acting through the general circulation. 



CHAPTER II. 

THE PATHOLOGY OF PAIN— NEURITIS, OR INFLAMMATION 
OF THE NERVES. 

As inflammatory conditions of the nerves con- 
stitute the most prolific source of pain, it is neces- 
sary to possess a general knowledge of the more 
common, and hence important, forms of neuritis. 

General Considerations. — The whole subject of 
neuritis, and particularly the part of it which relates 
to multiple neuritis, has received a vast deal of at- 
tention during the last few years. These studies — 
many of them at least — are important, not only on 
account of their immediate clinical bearing, but 
also because of the light which they have already 
shed and are destined in future to shed upon many 
disputed points in neuro-pathology. Let me illus- 
trate this point. Up to a comparatively recent 
period most of the text-books contained a more or 
less elaborate description of a form of paralysis the 
chief features of which are a motor paralysis which 
usually begins in the legs and spreads rapidly over 
the trunk to the arms. As a rule the medulla ob- 

3* 29 



30 PAIN. 

longata is involved, and there is usually, though 
not invariably, more or less fever. General sensi- 
bility and the functions of the bladder and rectum 
are but slightly affected ; there is no notable atrophy 
of the muscles, and consequently no diminution in 
the electrical excitability. !Nbw, this acute ascending 
paralysis, or "Landry's paralysis," as it has often 
been called in recognition of the accurate description 
which this writer was the first to publish, was for a 
considerable time almost universally classified among 
the diseases of the spinal cord, and this in the face 
of the fact that pathology afforded little or no justi- 
fication for such a step. It is not to be wondered 
at, therefore, that in default of tangible changes in 
the cord pathologists should ultimately have sought 
elsewhere for lesions of sufficient extent to account 
for the symptoms. Nor is it surprising that they 
should have turned their attention to the nerves, 
since by assuming a more or less general disturb- 
ance of these organs the symptoms — or at least 
most of them — might be logically accounted for. 
Thus it happened that as soon as the etiology 
and symptomatology of neuritis, and more espe- 
cially general neuritis, had become more thoroughly 
understood, neurologists were not slow to perceive 
the parallelism which exists between this affection 
and the group of symptoms heretofore known as 



31 

Landry's paralysis. So impressed is Ross with 
this resemblance that he has undertaken a most 
exhaustive study of all the cases of Landry's 
paralysis to be found in literature. From an anal- 
ysis of these cases (ninety-three in number) he con- 
cludes that Landry's paralysis is simply a variety 
of multiple neuritis. In this he agrees with the 
general deductions of Barth and Nauwerck, who 
have also conducted some important studies in the 
same field. The literature of the subject has also 
received copious additions from other sources. 

Before, however, pursuing this subject of multiple 
neuritis further I shall take the liberty of offering a 
few remarks on the simple or local form of nerve 
inflammation. 

Simple Neuritis. — The most frequent causes of 
this local form of neuritis are wounds, inflam- 
matory conditions in the vicinity of the nerve- 
stem, rheumatic influences culminating in thick- 
ening of the sheath, and tumors pressing upon 
the nerve. Severe compression of the nerve, caries 
of neighboring bones, and bruises may also give 
rise to it. To sum up the whole question of eti- 
ology, it may be stated that the restricted form of 
neuritis is more apt to be due to local than general 
causes ; while of multiple or general neural inflam- 
mations the reverse is true ; for toxic agents acting 



32 PAIN. 

more or less extensively throughout the organism 
play a prominent part in their causation. 

Symptoms. — The duration and course of simple 
neuritis is subject to a certain degree of variation. 
Usually, however, the onset is quite abrupt, although 
a gradual beginning is occasionally observed. An 
initiatory chill and fever are a feature in some cases, 
but the majority begin without these warnings. 

Whatever the precise mode of onset may chance 
to be, the first symptom to excite the apprehension 
of the patient is pain. This pain is usually severe, 
and is felt more or less throughout the distribution 
of the affected nerve. On applying gentle pressure 
along the course of the nerve, the latter is found to 
be extremely sensitive; and after the trouble has 
continued a certain length of time, it is often pos- 
sible to feel the nerve — which has become consider- 
ably thickened — through the integument. 

Though the pain is more or less persistent, it 
sometimes abates, but only to return again with 
renewed intensity. 

I have under my care at this time a patient in 
whom the intermittent and severe type of neuritic 
pain is well illustrated. The patient, a lady of high 
social position, was recently referred to me by Dr. 
M. S. Ayers, of New Jersey, for severe brachial 
neuralgia. On examination, I found the region 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 33 

along the course of the brachial plexus exceed- 
ingly sensitive to the touch, and the whole right 
arm hypersesthetic. 

Desiring to ascertain a possible cause for the 
neuritis, I investigated the case with considerable 
care, the patient herself aiding me in every way by 
her prompt and intelligent replies. Without enter- 
ing into unnecessary details, let me say that my 
attention was early directed to a swelling situated 
in the space above the clavicle immediately adjoin- 
ing the neck. This tumor was somewhat compres- 
sible ; there was pulsation, — whether external or in- 
ternal I could not tell, — and the region round about, 
and more especially at the anterior border of the 
enlargement, was quite tender to the touch. The 
point of interest, however, from an etiological point 
of view, was the fact that whenever the tumor was 
pressed upon, even to a moderate degree, the most 
excruciating pains were evoked in the region of the 
brachial plexus, and indeed throughout the entire 
arm. This left no doubt in my mind that the neu- 
ritis had been set up by the pressure of the tumor. 
Being in doubt, however, as to the nature of 
the latter, I called in consultation my friend Dr. 
John A. Wyeth, who, after a most thorough exam- 
ination, expressed the belief that the tumor was 
either a subclavian aneurism or a malignant tumor. 



34 PAIN. 

An operation having been decided upon, Dr. Wyeth 
cut down upon and extirpated the tumor, which 
on microscopical examination proved to be a sar- 
coma. Being closely adherent to the nerve, which 
it compressed, this tumor had given rise to a local 
neuritis of great severity. The patient made an 
excellent recovery, and there has been no return 
of the tumor. 

Disturbances of sensibility and motility also occur 
in neuritis as the direct result of interference with 
nervous conduction. Tingling, numbness, and a 
moderate degree of anaesthesia are observed in 
cases of medium severity; while in those charac- 
terized by more extensive and permanent changes 
in the nerve the anaesthesia may be profound. The 
magnitude of the motor derangements is also deter- 
mined by the vehemence of the neuritis : when the 
destruction in the nerve-fibres is of moderate ex- 
tent, the subject merely complains of weakness; 
but when the mischief is more serious, conduction 
is abolished; the muscle is paralyzed, and eventu- 
ally atrophies more or less extensively. At the 
inception of the atrophy the characteristic electrical 
reaction of degeneration may be obtained, so that a 
reliable prognosis may be given before the wasting 
is at all pronounced. 

Finally, extensive changes in the skin have been 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 35 

observed in a certain number of cases. The most 
common are vesicular and herpetic eruptions, glossy 
skin, and atrophy. The hair and nails may likewise 
be affected, the former becoming brittle and the 
latter stubby. 

Prognosis. — No very definite rules can be laid 
down as to the duration of the disease. Sometimes 
the symptoms are acute in character, attaining their 
maximum degree of development in a short time. 
In other cases the progress of the disease is insid- 
ious from the very beginning, there being neither 
chill, fever, nor an extreme degree of pain to mark 
its inception. Again, there may be an acute begin- 
ning and a rapid display of symptoms ; or the out- 
break of the disease is acute, while the evolution 
of symptoms is gradual. The latter cases belong 
in the category of so-called chronic neuritis. 

Whatever the particular mode of development 
may chance to be, the life of the patient is but 
rarely in jeopardy, and then only when the neuritis 
evinces a tendency to pursue an ascending course, 
in which cases important structures in the cerebro- 
spinal axis may be destroyed. In acute cases the 
recovery may often be exceedingly rapid, cessation 
of the inflammatory process and regeneration of the 
affected nerve-fibres taking place in an astonishingly 
short time. The residual mischief in a case of this 



36 PAIN. 

kind is insignificant. On the other hand, the 
chronic cases often last for months, and, even where 
recovery is apparently complete, there is always 
danger of relapse. 

Of course the presence of persistent and wide- 
spread atrophy of the muscles is unfavorable. In 
cases of this sort there is inevitably more or less 
pronounced impairment of motion. 

Pathology. — When the course of the disease is 
acute, the pathological changes are proportionately 
vehement. The aifected nerve is seen to be red- 
dened, swollen, and thickened; its vessels are 
distended and intensely hypersemic, to which cir- 
cumstance the lividity is due; there is a trans- 
udation of cellular elements and fluid from the 
engorged vessels into the interstitial tissue and 
nerve-sheaths ; and, in short, we have a typical 
picture of acute inflammation. On examining the 
nerve-fibres more closely, by the aid of good lenses, 
we find that the destructive process is by no means 
as far advanced in some as in others. In those 
which present the most marked changes the axis 
cylinder is completely obliterated, the medullary 
substance undergoes fatty or granular degeneration, 
and the sheaths themselves are more or less disin- 
tegrated. Finally, the disorganized remnants may 
be to a greater or less degree absorbed, and then 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 37 

nothing remains behind but the empty sheaths. 
This, as previously mentioned, is the course of 
events in the more severe cases; in those of a 
milder type, however, the changes are less far- 
reaching, nothing more than moderate swelling of 
the sheath and granulation of the medullary sub- 
stance being discoverable. 

Finally, cases which begin in a chronic manner 
do not present the primary stage of engorgement 
of the vessels and fluid and cellular infiltration. 

It has already been noted in the clinical portion 
of this chapter that some cases of a severer type 
get well without loss of power, provided the mus- 
cular atrophy has not been too extensive. This fact 
presupposes that the regenerative capacity of the 
peripheral nerves is prodigious. Considerable dif- 
ference of opinion exists among pathologists as to 
the manner in which this restoration of the nerve- 
filaments takes place. Of late, however, two theo- 
ries have chiefly claimed attention. According to 
the one, new axis cylinders are evolved and pro- 
longed from those which have escaped the ravages 
of the inflammation; while the other affirms that 
the young nerve-fibres are derived "from an en- 
dogenous growth of nuclei within the Schwann's 
sheath." Beneke and Neumann are adherents of 
this hypothesis. 



38 PAIN. 

In connection with traumatic neuritis the facts 
bearing on the regeneration of divided nerves are 
strikingly exhibited; for, from what has been 
learned both experimentally and in the clinic, it is 
certain that more or less perfect union and restora- 
tion of function may be obtained in nerves which 
have been considerably mutilated. 

Thus, Gluck found, in the course of a series of 
experiments on fowls, that excision of a piece of 
nerve was not followed by restoration of function, 
but that, after simple division, such restoration 
readily took place when the ends were carefully 
coaptated. This renewal of conduction was, more- 
over, established with marvellous rapidity, — in two 
instances in twenty-four hours. As a rule, however, 
when the sciatic was divided and the ends imme- 
diately joined with sutures, paralysis of the muscles 
supplied by the nerve persisted for fifty hours. After 
the lapse of this interval there was a gradual resump- 
tion of motion in the affected muscles, more or less 
complete recovery taking place in about four days. 

Waller and Vaulair believe that the regeneration 
takes place from the central end of the divided 
nerve, and that the peripheral end degenerates. 
Tizzoni, on the other hand, holds that the degenera- 
tion affects both ends of the nerve at the point of 
incision. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 39 

Eichhorst and Mayer maintain that the reorganiza- 
tion takes place from the nerve-fibres on both sides 
of the incision, the new connecting fibres being 
derived from the axis cylinders ; while Ranvier has 
indicated the important part played by the mechan- 
ical support of the tissues in maintaining the physi- 
ological distribution of regenerated nerves. In my 
opinion, the regeneration of the nerve is effected, 
or largely effected, from the central end, substan- 
tially as described by "Waller and Yaulair. 

Lastly, Paget has found that after division of the 
median nerve sensation began to appear in the 
regions supplied by it within two weeks. Recovery 
was practically complete in about four weeks. As 
has already been said, the accurate coaptation of 
the ends of the nerve at the point of division favors 
cicatrization and regeneration, and hence the fre- 
quency and success with which the process has 
been resorted to by modern surgeons. 

From the above data it is evident that considerable 
difference of opinion exists among pathologists re- 
garding the remarkable series of events which cul- 
minate in the restoration of function in a nerve 
previously injured either by the knife or the inroads 
of active inflammation. Nevertheless, many of the 
phenomena observed are exceedingly suggestive, 
and it is, moreover, highly probable that some at 



40 PAIN. 

least of the points in dispute will be definitely set- 
tled in the near future. 

The measures applicable in the management of 
neuritis are such as tend to reduce the inflammation 
and allay the pain. Of the former, local measures, 
such as hot applications, vesicants, and rest, are of 
the first importance. In addition to these, some 
authors recommend cold, applied either by means 
of the ice-bag or rubber coil. For my own part, I 
much prefer heat, which I am in the habit of em- 
ploying in the form of cloths, which have been 
previously dipped in hot water and then carefully 
wrung out before wrapping them about the affected 
limb. Blisters, too, undoubtedly do good, especially 
in the less acute cases ; and, indeed, the same may 
be said of galvanism, which often sensibly moder- 
ates the feeling of soreness, possibly by diminishing 
the hypersemic condition in and about the nerve- 
stems, or merely by exerting a counter-irritant 
effect. 

Kest has also been spoken of; let me once more 
insist upon its great importance ; for nothing in the 
mode of life of the patient should be tolerated which 
allows or compels him to move about a limb which 
is the seat of neuritis. It is, indeed, advisable to 
insist upon his remaining in bed when a lower 
limb is involved, or upon the application of a sim- 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 41 

pie splint or sling when the nerves of the arm are 
affected. 

Lastly, there should be no hesitancy in invoking 
the aid of analgesis in order to control the severe 
paroxysms of pain which are so characteristic of 
the disease. Morphine in moderate doses, especially 
when combined with phenacetin or antipyrin, some- 
times answers ; but, as a rule, it is necessary to give 
the former remedy in large doses, of from one-quar- 
ter to one-half grain, in order to obtain appreciable 
relief. In the section devoted to the general princi- 
ples of treatment the application of remedies will 
be more fully considered. 

Multiple Neuritis. — In this form of neuritis we 
have to do with a symmetrical and more or less 
widely disseminated inflammation or degeneration 
of the sensory and motor nerves, particularly the 
latter. As a rule, the cerebral and bulbar nerves 
are little or not at all affected. Since Dumenil 
published his excellent paper in 1864, a multitude of 
observers have come forward; and, indeed, hardly a 
year goes by without witnessing extensive additions 
to the literature of the subject. At the present 
time the available material is quite overwhelming, 
so that detailed references to it would only tend to 
add confusion to a subject already sufficiently in- 
volved. I shall, therefore, content myself with a 

4* 



42 PAIN. 

more general method of presentation, leaving the 
reader to work up for himself such points as he 
may be specially interested in. 

To begin with the etiology, it is necessary to 
bear in mind that disseminated inflammation of 
the nerves may be induced by an extensive array 
of causes, among which toxic and infectious agents 
occupy a conspicuous position. Prominent among 
these are lead, alcohol, illuminating gas, bisulphide 
of carbon, arsenic, aniline, dinitro-benzine, phos- 
phorus, mercury, morphine, and ergot; and among 
animal and endogenous poisons fevers of various 
kinds, diphtheria, tuberculosis, beriberi, leprosy, 
malaria, la grippe (influenza), and gout, rheuma- 
tism, the puerperal state, chorea, and diabetes. 
In addition to these, dyscrasic conditions un- 
doubtedly play a part in the evolution of certain 
cases. Thus, an attack of neuritis is a frequent 
concomitant of diseases of the blood-vessels, ma- 
rasmus, chlorosis, and cancer. 

A large proportion of cases begin acutely, a 
smaller number develop more gradually, while 
a third class display great lethargy in the evo- 
lution of the different symptoms. Hence it is 
customary in some of the books to describe an 
acute, a subacute, and a chronic form of the dis- 
ease. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 43 

Besides these varieties, Ross, who has recently 
published a series of most exhaustive papers on 
the subject, introduces some other forms in his 
classification. Sensory, vaso-motor, and trophic 
neuritis, as well as the irritative form,— which in- 
cludes professional hypercinesia and tetany, — are 
assigned a prominent place in his classification. 
Under the head of sensory neuritis he places the 
so-called neuro-tabes peripherica, or that form of neu- 
ritis which occurs in ataxia; Weir Mitchell's neu- 
rosis (erythromelalgia) is classed as a vaso-motor 
neuritis ; and, finally, Raynaud's disease is the rep- 
resentative of the trophic form of neuritis. The 
latter part of this classification of Ross — more espe- 
cially that which relates to tetany — has not yet met 
with general acceptance, largely on account of the 
meagre support which it has thus far received from 
pathology. With this exception, the classification 
leaves nothing to be desired. 

It would be a simple waste of time to enter into 
a separate description of all these different forms of 
neuritis ; for, however they may differ in causation, 
they all display a remarkable family likeness. For 
this reason I shall endeavor to give a general ac- 
count of the disease, embracing all its more charac- 
teristic features, by the aid of which I trust the 
reader will be able to arrive at a diagnosis, even 



44 PAIN. 

when the complicating factors in a given case are 
considerable. 

General Symptoms of Multiple Neuritis. — Quite 
a large proportion of cases of multiple neuritis, of 
whatever cause, begin abruptly. It is true that the 
patient may complain for some days of vague feel- 
ings of malaise and weakness, especially in the 
lower limbs ; but these sensations commonly excite 
little or no attention, and not until more definite 
symptoms are added is medical aid invoked. At 
this time he suffers perhaps from vague discomfort 
in the head, loss of appetite, and mental hebetude, 
and he may even be delirious. There may also be 
considerable fever, the temperature reaching 101° 
or even 105°, while the pulse is correspondingly 
accelerated. Sometimes, however, the evolution 
of the symptoms, even in the beginning, is more 
gradual, and it is then quite difficult to predict 
what is really impending. Whatever phase these 
premonitory phenomena may assume, however, they 
are certain, or almost certain, to be speedily fol- 
lowed by symptoms of sensory irritation. The 
subject complains of tingling, numbness, crawling 
sensations, and pain. These symptoms are especially 
pronounced in the affected limbs, and they evince, 
as may readily be imagined, a decided predilection 
for the regions in the vicinity of the nerves. While 



45 

sensory irritation is apparent from the beginning, 
the opposite condition of sensory paralysis is by no 
means so obvious. It is true that the muscular 
sense may be so impaired as to give rise to pro- 
nounced ataxia ; the tactile sense, too, may be more 
or less affected, and the transmission of sensations 
of heat and cold, as well as those of pain, may be 
considerably retarded. Still, it must be borne in 
mind that, when the sensations reach the central, 
perceptive mechanism, they possess considerable 
vigor, and are therefore felt with great distinctness. 
Complete anesthesia then is decidedly exceptional. 

The distribution of these paresthesia is a matter 
of some interest. Sometimes they are associated 
with the ramifications of a particular nerve, while 
at others they are distributed in irregular islands 
without obvious physiological connection ; or, finally, 
they may pervade the entire limb. In any event, 
their presence is significant and often of the first 
importance in forming a correct diagnosis. 

The pains, too, when taken in connection with 
the other features of the case, are of value in 
forming an opinion as to the nature of the disease. 
Though somewhat like those of locomotor ataxia, 
they differ notably in this, — that whereas in multiple 
neuritis the pains are readily evoked by pressure 
upon the nerves, this is not usually the case in 



46 PAIN. 

ataxia. With the advent of these pains there is 
sometimes more or less oedema, profuse diaphoresis, 
or swelling of the joints; this is especially true of 
the epidemic variety of neuritis. The last-named 
symptom has frequently caused the case to be mis- 
taken for acute articular rheumatism. 

Eot less important than the sensory symptoms 
are the derangements of motility. The latter, 
unlike the former, are non-irritative in type, paral- 
ysis of motion being the rule, while spasms are rare. 
In the majority of cases the paralysis begins first 
in one leg, speedily involves the other, and may 
advance thence to one or both arms. As a rule, 
the invasion is rapid, the loss of power beginning 
as a simple sensation of weakness on standing or 
walking, and culminating in more or less complete 
paralysis in fifteen or eighteen days. The distribu- 
tion of the paralysis presents some points of interest. 
In the first place, it is a remarkable fact that the 
muscles concerned in the manipulation of the small 
joints of the hands and feet and of the wrists and 
ankles are much more affected than those of the 
elbows and knees. Thus, in a case which I recently 
saw in consultation with Dr. Eleanora Haines, of 
Newark, the patient, a man of sixty, who was a 
sufferer from multiple neuritis of malarial origin, 
was able to move both elbows and knees without 



PHYSIOLOGICAL, PATHOLOGICAL, CLIXICAL. 47 

difficulty, while voluntary motion in the wrists and 
ankles was quite impossible. Another interesting 
point is, that the paralysis shows quite an irregular 
distribution at first, but assumes the characteristic 
form when fully developed. I emphasize this point 
because one who sees the case at the commence- 
ment of the paralytic invasion is apt to be puzzled, 
unless forewarned of the erratic course of the symp- 
toms. 

Such, then, is the course of events in an ordinary 
case of neuritis. Exceptionally, however, the clini- 
cal picture is considerably modified. Thus, as a 
rule, the cerebral and bulbar nerves are not in- 
volved; and yet, in fatal cases, the pneumogastric 
is invaded, deglutition becomes difficult, and the 
patient dies as the result of complications analogous 
to those of bulbar paralysis. In another and smaller 
class of cases some of the cranial nerves — notably 
those of the eyes, and more rarely those of the face — 
become implicated. Lastly, in a larger number, the 
paralysis extends to the muscles of the trunk, and 
those of the arms and thighs as well. Such cases 
are liable to prove fatal on account of the implica- 
tion of the muscles concerned in respiration ; this, 
indeed, is the most frequent cause of death in the 
severe multiple neuritis which accompanies alcohol- 
ism and the disease known as " kakke," or " beri- 



48 PAIN. 

beri." In a large percentage of cases of ordinary 
type, however, more or less perfect recovery takes 
place. The precise amount of power regained by 
the affected muscles will be determined by the ex- 
tent to which they have atrophied ; for, as a matter 
of fact, such atrophy occurs in the majority of cases 
which pursue an erratic and chronic course. The 
tendon reflexes are always lost when the paralysis is 
at all considerable. On the other hand, the function 
of the bladder and rectum usually remain unaf- 
fected. Such are the more important features of 
multiple neuritis. 



SPECIAL TYPES OF NEURITIS. 

CHRONIC ALCOHOLIC NEURITIS — NEURITIS FOLLOWING IN- 
FLUENZA — THE NEURITIS OF LEPROSY— BERIBERI. 

While the foregoing description affords a general 
survey of multiple neuritis, there are certain types 
of the disease endowed with sufficient individuality 
to justify separate consideration. This applies es- 
pecially to chronic alcoholic neuritis, the neuritis of 
leprosy, and the disease known as "beriberi," or 
" kakke." 

Chronic Alcoholic Neuritis, or the Pseudo-Ataxia 
of Drunkards. — One of the most interesting phases 
of alcoholic poisoning is that characterized by 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 49 

symptoms which bear the closest resemblance to 
those of locomotor ataxia. The disease commonly 
begins with lancinating pains in the lower limbs; 
these may or may not extend to the arms ; but, in 
any event, they are usually quite severe. In the 
course of weeks, months, or even years, the gait of 
the patient becomes more or less affected. When 
he attempts to go about, he is troubled by weakness 
and inability to control the muscles ; and a careful 
examination reveals the fact that there is more or 
less true paralysis and atrophy combined with the 
muscular incoordination, — an important distinction, 
by the way, from true locomotor ataxia. On tap- 
ping the patellar tendons, there is little or no re- 
sponse; and the customary electrical tests, when 
applied to the affected muscles, elicit the reaction 
of degeneration. In addition to these symptoms, 
there may usually be discovered more or less ex- 
tensive zones of anaesthesia in the affected limbs; 
while pressure upon the nerves shows them to be 
quite sensitive, though not to the same degree as in 
the more acute forms of the disease. 

This is a fairly complete presentment of the affec- 
tion as we commonly find it. There are cases, 
however, in which its complexion is greatly altered. 
This atypical aspect is largely due to the prominence 
of the atrophic, paralytic changes, the sensory dis- 



50 PAIN. 

turbances remaining quite subordinate from the 
beginning. 

As may readily be imagined, a group of symp- 
toms of this kind may be mistaken for true ataxia, 
especially in the beginning. Later, the absence of 
such ataxic symptoms as bladder disturbances, gird- 
ling pains, and the Argyll-Robertson pupils, will 
assist in the formation of a correct diagnosis. 

Neuritis folio wingr Influenza. — During the epi- 
demics of the " grippe" which have been so com- 
mon during the last few years, excellent opportu- 
nities have been afforded of observing the various 
nervous disturbances so characteristic of that pro- 
tean affection. 

Among these there are none more interesting 
than the inflammatory conditions of the nerves, 
which are the direct result of the systemic poison- 
ing. The symptoms of this form of neuritis resem- 
ble somewhat those of the alcoholic form of the 
disease, if we except the mental manifestations 
which are absent. 

The inflammation is frequently bilateral, invading 
corresponding nerves on both sides of the body, 
and giving rise to more or less extensive paralysis 
and atrophy. When the disease involves both sciatic 
nerves, as was the case in a man whom I saw in 
consultation with Dr. G. F. Pitts, of New Jersey, 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 51 

it may be mistaken for grave disease of the spinal 
cord; but the exquisite tenderness of the nerves 
and the absence of bladder and rectal symptoms 
will usually serve to reveal its true peripheral 
nature. 

Gowers has recently published a highly suggestive 
paper on this type of neuritis. 

The Neuritis of Leprosy. — Although alterations 
of greater or less extent have been noted in the 
cerebro-spinal axis, and especially in the cord, in 
leprosy, these appearances must be regarded as 
exceptional, inasmuch as many observers have seen 
them but rarely, while others have altogether failed 
to find them. On the other hand, nothing is more 
certain than that inflammations of the nerves, as- 
suming the form of interstitial and parenchymatous 
neuritis, play an important part in the evolution of 
many of the symptoms of this dreadful disease. 
Leloir, 1 in his classical monograph, has given an 
elaborate account of the genesis of this neuritis. 
According to his researches, which in their main 
features coincide with those of Neisser and Hansen, 
the inflammation of the nerve is due to the virus 
of the micro-organism of leprosy; for this bacillus 

lr Traite Pratique et Theorique de la Lepre, by Henri Leloir, 
Paris, 1886, p. 248. 



52 PAIN. 

is to be found either between the nerve-tubules 
or in the inflamed interstitial tissue. 

To thoroughly comprehend the significance of 
these changes in the peripheral nerves it is neces- 
sary to remember that there are two principal forms 
of leprosy, the tubercular and the anaesthetic or tro- 
phoneurotic form ; and that in the first variety the 
energy of the disease is largely directed to the in- 
tegument, while in the second it tends chiefly to 
the nerves. Between these two extreme varieties 
various transitional forms occur ; so that we some- 
times find the tubercular phase of the disease merg- 
ing into anaesthetic or tropho-neurotic leprosy. This 
combination of the tubercular and anaesthetic forms 
is referred to by Leloir as " mixed" leprosy. 

Instead of considering the tubercular and trans- 
itional phases of the disease, which belong, strictly 
speaking, in the domain of dermatology, I shall 
proceed at once to a more extended examination 
of the anaesthetic or tropho-neurotic form; for it 
is in the latter that the changes in the peripheral 
nerves are at once most extensive and far-reaching 
in their clinical effects. Another reason for exam- 
ining the phenomena of this form of leprosy more 
closely is found in the close resemblance which they 
bear to those of syringomyelia. I shall return to 
this point later on. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 53 

Symptoms of the Anaesthetic Form of Leprosy. 
— As previously intimated, the symptoms of this 
form of the disease are all, or nearly all, attribu- 
table to the alterations in the nerves. So certain has 
this become through the combined evidence of the 
dead-house and clinic that, as Leloir cogently puts 
it, the study of the anaesthetic or tropho-neurotic 
form of leprosy is nothing more than the study of 
a variety of neuritis. 

While there is usually no fever in the beginning, 
the onset of the disease is marked by the occur- 
rence of disturbances of sensibility of various kinds, 
notably burning, tingling, itching, and hyperesthesia 
of the skin. The macular spots of the early erup- 
tive stage are at once pigmented and hyperaemic in 
appearance. In the beginning of their development 
they are less livid, but by degrees they merge into 
gray, brown, or yellow. The subsequent evolution 
of these patches is thus graphically described by 
Dr. Prince A. Morrow, 1 who has devoted careful 
study to the disease as it appears in the Sandwich 
Islands and among the Chinese of San Francisco. 
" They are usually persistent," he says, " and mani- 

1 The Diagnosis of Leprosy, especially the Differentiation of the 
Anaesthetic Form from Syringomyelia, by Prince A. Morrow, 
M.D., etc., Journal of Cutaneous and Genito-Urinary Diseases, 
January, 1890, p. 7 et seq. 

5* 



54 PAIN. 

fest a tendency to clear up in the centre while 
spreading at the periphery. By this mode of cen- 
trifugal extension and the coalescence of contiguous 
patches they form arcs of circles and large gyrate 
patches, with slightly elevated margins of a reddish- 
brown, port-wine, sepia, or slaty color." 

Upon their first appearance these macules are 
hyperaesthetic, "but as the central portion closes 
up the hyperesthesia recedes to the pigmented 
periphery and is replaced by anaesthesia of the 
centre." This interesting phenomenon leads Mor- 
row to the hypothesis " that in the evolution of 
these macules, hyperchromia and hyperesthesia, 
achromia and anaesthesia, are associated and ad- 
vance pari passu.' 9 Sometimes, however, instead 
of following the mode of development just de- 
scribed, the pigmentary changes are achromic or 
hyperchromic from the beginning. 

Besides the neurotic anomalies just considered, 
we may also encounter both sensory and motor 
disturbances of much greater extent. Thus, very 
large areas of the skin may be the seat of anal- 
gesia and insensibility to temperature as well as 
atrophic changes; while, at the same time, the 
further extension of the neuritic changes to im- 
portant motor nerves may cause more or less ex- 
tensive paralysis and atrophy of the muscles. To 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 55 

these changes in the skin and muscles various 
lesions of the bones and joints are added, and 
these are apt to culminate sooner or later in 
more or less extensive mutilations. The macular 
spots previously described are not the only dermal 
changes in leprosy ; for, in addition, pemphigoid le- 
sions of a severe type are common enough. Some- 
times, however, all, or nearly all, of these dermal 
appearances are absent; and in such anomalous 
cases the sensory or motor impairment may be the 
chief or even the sole feature. Under these cir- 
cumstances a correct diagnosis is, as a matter of 
course, most difficult. 

Lastly, the nerves most frequently involved are 
the nervus cutaneus palmaris, in which the neu- 
ritic changes commonly begin, when the upper 
extremity is affected, and the nervus peroneus 
and nervus cutaneus femoris posterior externus, 
which are first impaired when the disease begins 
in the legs. In addition to these changes in the 
cutaneous nerves, the large deep-seated nerves also 
undergo degeneration ; hence the extensive paral- 
yses and atrophy of the muscles. However, even 
when the disease has lasted a long time, all the 
nerves are by no means equally affected. Thus, 
the third or seventh pair of cranial nerves may be 
predominantly involved, and we then have derange- 



56 PAIN. 

ment of the motor apparatus of the eye, or paralysis 
of the muscles of the face, with the characteristic 
distortion of the mouth. Again, the neuritis may 
evince a predilection for the nerves of the arm, 
and notably the ulnar nerve, and we then have 
atrophic changes in the muscles of the hand and 
arm quite like those which constitute the main 
en griffe of progressive muscular atrophy. The 
presence of profound anaesthesia will, however, 
serve to differentiate the condition from the last- 
named affection. 

Mention has already been made of the great 
difficulties which sometimes beset the differential 
diagnosis of leprosy from syringomyelia. A refer- 
ence to the symptomatology of the last-named 
affection will serve to show why this should be 
so. In the face of such obstacles it would probably 
be rather premature to lay down arbitrary rules 
governing the differentiation of the two affections, 
especially when the leprosy is at all atypical. 

For many details of the preceding description 
and for valuable information regarding the whole 
subject of leprosy, I desire to express my indebted- 
ness to Dr. Morrow, whose practical knowledge of 
the disease gained by prolonged study in the Sand- 
wich Islands is unsurpassed. 

Beriberi. — Scheube was the first to show that the 



57 

remarkable disease variously known as "beriberi" 
and " kakke," which occurs in the East Indies and 
Japan, is nothing more nor less than a form of mul- 
tiple neuritis. Since the publication of Scheube's 
paper it has furthermore been shown that this 
neuritis is directly due to the presence in the sys- 
tem of a peculiar micro-organism. These and mi- 
crococci bacilli may be detected in the blood of 
persons suffering from beriberi; and, what is still 
more conclusive, pure cultures of the micrococci 
cause, when injected into dogs and rabbits, changes 
in the nerves similar to those found in beri- 
beri. 

It is probable that the infecting substance usually 
gains access to the body through the respiratory 
apparatus, although infection through the clothing 
is not uncommon. On the other hand, some ob- 
servers, among whom is Nimra, believe that intro- 
duction of putrid fish of the genus Scomiridse is 
the principal, if not the sole, cause of the disease. 
The bulk of evidence, however, goes to show that 
beriberi is an infectious disease, principally trans- 
missible through the air and clothing. 

Symptoms of Beriberi. — It is not an altogether 
easy task to give a general description of beriberi, 
since the disease presents itself under a multitude 
of guises ; still, a certain number of more or less 



58 PAIN. 

well-marked forms are discernible. These are, 
however, closely united clinically by various transi- 
tional phases, while in a pathological sense they 
are, of course, identical. 

All forms of the disease present a more or less 
marked initial stage. The patient is conscious of 
being unwell ; he is listless, feverish, and easily 
tired by walking ; his conjunctivae are injected and 
more or less acutely inflamed ; he has some watery 
discharge from the nose ; and he suffers from weak- 
ness and a general sense of bodily discomfort. 
These premonitory symptoms are soon followed by 
tingling, numbness, and more or less pain in the 
lower limbs, as well as pronounced motor impair- 
ment and oedema. A most important symptom at 
this time is weakness and rapidity of the heart's 
action ; and to its presence is doubtless to be ascribed 
the cedematous condition of the legs and arms pre- 
viously referred to. 

In addition to the sensory impairment, there is 
marked paresis and absence of the tendon reflexes. 
Ataxia as we find it in alcoholic cases is, however, 
absent. The future course of the disease is either 
favorable or unfavorable. When favorable, recovery 
takes place in ten days or six weeks, or exception- 
ally, in chronic cases, in from sixty to ninety days; 
when unfavorable, various other grave symptoms are 



PHYSIOLOGICAL. PATHOLOGICAL, CLINICAL. 59 

added, and the patient either dies or recovers, but 
only after a long illness. 

Let us consider the symptoms which are peculiar 
to the less favorable cases. In the first place, the 
oedema previously alluded to as a feature of the 
mild cases may assume unusual proportions, so that 
effusion takes place into the pleural and peritoneal 
cavities, as well as into the subcutaneous tissue. 
The entire body of a person afflicted in this way 
is enormously swollen, the action of the heart is 
greatly reduced in vigor, paralysis more or less ex- 
tensive is always present, and the affected muscles 
atrophy precisely as in other forms of neuritis. This 
wasting of the muscles is not visible to the eye on 
account of the oedema, but it may often be ascer- 
tained by careful palpation. This is the so-called 
hydropic form of the disease. Again, there may be 
little or no oedema ; but, as if to compensate for its 
absence, the sensory and motor disturbances are 
more extensive and severe. 

The muscles of the entire body atrophy; sensi- 
bility is so exalted that the patient can hardly en- 
dure the weight of the bedclothes ; he suffers more 
or less acute pain; and his general appearance is 
that of an individual in the last stages of phthisis. 
In some cases the hypersesthesia is succeeded by 
a certain degree of anaesthesia, and there may be 



60 PAIN. 

delay in the transmission of painful sensations, as 
in ataxia ; but, as a rule, variations in temperature 
are perceived even when the disease is at its height. 
This is the dry or atrophic form of the disease. 
Finally, the symptoms of the hydropic and atrophic 
types may be combined. Cases of this kind pursue 
an acute course, and death usually takes place from 
heart-failure. In both the hydropic and atrophic 
phases of the disease recovery takes place in a large 
proportion of cases, but only after a long period 
of convalescence. In the fatal cases death results 
from some intercurrent aifection or from exhaustion. 
Diagnosis. — From what has already been learned, 
it is evident that the diagnosis of the disease may 
present certain difficulties. Two affections in par- 
ticular — locomotor ataxia and poliomyelitis — have 
often been mistaken for it. For purposes of dif- 
ferentiation, the sensory symptoms occurring in the 
beginning of most cases of multiple neuritis are of 
the first importance. Especially may this be said 
of the extreme sensitiveness of the nerves and 
muscles to pressure, — a condition which is foreign 
to both ataxia and poliomyelitis. In ataxia, more- 
over, the characteristic incoordination of the mus- 
cles is developed slowly, there is no true paralysis 
of the muscles nor atrophy, and the pupillary reac- 
tions are interfered with (Argyll-Robertson pupil). 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 61 

In multiple neuritis, on the other hand, the loss of 
power is rapid, the affected muscles atrophy, and 
there are no abnormal changes in the pupil. 

Prognosis. — From what has previously been said, 
it is evident that the prognosis is fair in many phases 
of multiple neuritis. It is, of course, positively un- 
favorable in those cases of neuritis which develop 
in the course of leprosy, beriberi, tubercular disease, 
and less so in alcoholism. In expressing an opinion 
as to the probable outcome in a given case great 
caution should, however, be exercised, as both the 
laboratory and clinic have repeatedly shown how 
great is the power of regeneration possessed by the 
peripheral nerves as contrasted with other portions 
of the nervous system, and notably the spinal cord. 

The anatomical changes in the acute cases are 
essentially inflammatory, while in those which 
pursue a chronic course they are of the nature of 
a degenerative atrophy. Moreover, the ramifica- 
tions of the nerves are more profoundly affected 
than the stems. 

As the minute pathological changes have already 
been discussed under the head of simple neuritis, 
nothing further need be said of them. 



CHAPTER III. 

CONCERNING PAINS LOCATED IN DEFINITE NERVE-AREAS — 
NEURALGIA. 

From what has previously been said, it is evident 
that every painful impression must be due to an 
irritation of one or several nerves, and it has also 
been shown that the usual source of such morbidly 
increased stimulation is neuritis. Inflammation of 
the nerves cannot, however, be regarded as the only 
cause of pain, as some authors would have us be- 
lieve. There are, indeed, certain fugitive pains 
whose advent and subsidence are so sudden as to 
preclude the development of true inflammation. In 
my opinion, such pains are usually attributable 
either to a molecular or circulatory disturbance in 
the nerve, due to an external agent, such as cold, 
or they are traceable to a toxic agent temporarily 
contained in the blood. Some of the painful ner- 
vous disturbances consecutive to influenza are ap- 
parently of this character, though others, as Gowers 
has recently pointed out, are traceable to neuritis. 
Whatever may be the opinion held, then, regarding 
62 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 63 

evanescent pains, it must be assumed that where the 
morbid sensation is both localized and persistent, as 
in neuralgia, we have indeed to do with a veritable 
inflammation of the nerve. Hence it follows that 
the causation of these local pains or neuralgias is 
substantially that of neuritis. 

From the foregoing, it is evident that what is 
currently known as neuralgia may be defined as an 
affection of the nerves, characterized by the occur- 
rence of sudden, severe paroxysms of pain in re- 
gions supplied by one or several nerves. 

For purposes of exact designation these pains 
have been classified according to the nerve-stem or 
branch chiefly implicated. 

All these forms of neuralgia have certain common 
attributes, the variations in symptomatology being 
contingent, or largely contingent, upon differences 
of locality. It is apparent, therefore, that some 
preliminary observations of a general character will 
save much needless repetition. 

The onset of the affection is usually heralded by 
vague muscular twitchings or sensations of pricking, 
quickly succeeded by darting pains. The pains are 
recurrent in character, following each other with 
ever-increasing frequency and intensity, until, in 
the more severe attacks, the patient suffers the most 
excruciating agony. In some cases the pains are 



64 PAIN. 

darting or lancinating, whereas in others they are 
compared with the prick of red-hot needles. 

The pains, as previously observed, are usually 
localized, and the subject declares that, however 
long may be the intermission between the parox- 
ysms, the pains always return to the same locality. 
Such is apt to be the case where the neuritis is 
restricted to a single nerve or one or more of its 
principal branches. 

Sometimes, however, the neuritis is much more 
widely distributed, and, as a consequence, the pains 
dart about from place to place, first one part of the 
affected region being assailed and then another. 

When subjected to pressure the nerve is found to 
be extremely tender, the hyperesthesia being either 
circumscribed, so as to constitute the so-called "points 
douloureux" or more widely distributed, giving rise 
to irregular areas of great tenderness in the skin. 

Should careful exploration with the finger fail to 
disclose these painful spots, the passage of the fa- 
radic current through the suspected locality, either 
by the aid of a small sponge electrode or the wire 
brush, will at once reveal their presence. 

Another noteworthy circumstance is, that when, 
in the course of an attack of severe neuralgia, — 
especially that of an intercostal or lumbar type, — 
pressure is applied along the spine, painful areas 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 65 

corresponding to the origin of the affected nerves 
are frequently found. 

But pain is not the only sensory disturbance met 
with in neuralgia, since formication, numbness, and 
even anaesthesia are quite common. 

Where the anaesthesia is well marked and exten- 
sive, it is evidence that the inflammatory changes in 
the nerve are severe enough to interrupt conduc- 
tion, a fact which has an obvious bearing on the 
prognosis. On the other band, the irritative phe- 
nomena may be of such a violent character as to 
completely overshadow all other elements in the 
case. Under these circumstances reflex muscular 
spasms are apt to develop ; so that, in neuralgia of 
the trigeminal nerve, the facial muscles may be 
sufficiently convulsed to cause grotesque distortion 
of the countenance; while, in the same way, the 
presence of neuralgia in one of the limbs may 
give rise to muscular contractions which may be 
restricted in character or involve the entire limb. 

These spasms are so clearly of reflex origin that 
the mode of their genesis is hardly to be regarded 
as an open question. 

Persons of weak constitution, or those in whom 
debility, resulting from disease or excesses, has 
materially curtailed the powers of resistance origi- 
nally inherent in the organism, are especially exposed 

6* 



66 PAIN. 

to neuralgia. This is equivalent to stating that they 
inevitably invite an attack of neuritis, since they 
are susceptible alike to cold and septic influences 
of all kinds. 

The following are the more important manifesta- 
tions of the affection in different localities : 

In trigeminal or facial neuralgia the pain may 
involve the entire lateral half of the face and head 
when all three branches of the nerve are involved, 
but is much restricted when but one branch is im- 
plicated. Thus, when the neuritic condition is con- 
fined to the supraorbital or ophthalmic branch, the 
pain is felt in the forehead and upper eyelid, and 
is accompanied by more or less lachrymation. In 
neuralgia of the supramaxillary branch the pains 
are located in the eyelid, cheek, nose, upper lip, 
nasal cavities, gums, upper teeth, zygomatic arch, 
and temporal region; whereas implication of the 
entire inframaxillary branch gives rise to pain in 
the lower teeth and jaw, the mucous membrane 
of the mouth, the tongue, the chin, the cheek, and 
the external auditory meatus and auricle. 

The vaso-motor disturbances of facial neuralgia 
consist in coldness and pallor, which may later give 
place to an cedematous and glossy skin. Allusion 
has already been made to the reflex muscular 
spasms which sometimes accompany the severer 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 67 

types of the disease, so that nothing further need 
be said regarding these interesting appearances. 

Severe mental depression, irritability, and insom- 
nia are common accompaniments of facial neuralgia; 
and when the paroxysms become chronic, there is 
a progressive physical and mental deterioration, 
which may drive the unhappy sufferer to seek 
relief in self-destruction. In a subsequent chapter 
I shall indicate the most effective measures to be 
adopted in dealing with these distressing complica- 
tions of pain. 

In cervico-occipital neuralgia, the region supplied 
by the great occipital nerve is the principal seat of 
pain ; but exceptionally it may be reflected to the 
neck and lower part of the face. 

The pains of cervico-brachial neuralgia are felt in 
the subclavian region and throughout the upper 
extremity. Should, however, the plexus be only 
partially invaded, the pain is, of course, much less 
widely distributed. Where these conditions prevail 
it may be difficult to determine what branches of 
the plexus or nerve-roots are predominantly in- 
volved. 

In crural neuralgia the pains are chiefly felt along 
the anterior and inner aspects of the thigh. 

When the first pairs of the lumbar nerves are 
involved the pain is restricted to the loins ; whereas 



68 PAIN. 

in lumbo-abdominal neuralgia it extends to the hy- 
pogastrium, and may also include the scrotum or 
mons veneris. 

The back and the walls of the thorax are the seat 
of pain in dorso-intercostal neuralgia ; but it often 
happens that it is more acutely felt in the former, 
and is then commonly referred to as lumbago. 

In sciatic neuralgia the pain extends from the 
gluteal region down the posterior aspect of the 
thigh and leg ; and at the point of emergence of 
the nerve from the plexus a spot of unusual tender- 
ness is usually present. Plantar neuralgia, which 
was first accurately described by Dr. "Weir Mitchell, 
is characterized by severe pain in the sole of the 
foot. Both feet are usually affected, and there is 
more or less redness and swelling. 

The designation coccygodynia has been applied 
to those severe pains in the coccyx due to difficult 
labor, injuries, inflammation, caries, and other 
causes which may give rise to secondary inflamma- 
tory changes in the coccygeal plexus. Extirpation 
of the coccyx is really the only effectual treatment. 

Mastodynia, or " irritable breast," as it is often 
called, is nothing more than a variety of intercostal 
neuralgia, and is amenable to the same treatment 
as other forms of localized pain. 

Muscular neuralgia is the conventional term em- 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 69 

ployed to designate a painful condition of the 
muscles, which may exist in the absence of all 
tenderness of adjacent nerve-stems. 

The muscles of the back and neck are those most 
frequently implicated. 

Let me add, in concluding this brief survey of 
the more important features of neuralgia, that the 
prognosis is substantially that of neuritis, as stated 
in the preceding chapter. Where the neuritic 
changes are of recent occurrence, permanent relief 
may generally be afforded without much difficulty ; 
but when they are of long standing, the outlook, 
though far from hopeless, is less favorable. The 
whole question of treatment will, however, be thor- 
oughly discussed in the chapter devoted to the 
therapeutics of pain. 



CHAPTER IV. 

PAIN ASSOCIATED WITH THE RHEUMATIC AND GOUTY 
DIATHESIS. 

Though the ultimate pathology of both these 
affections is, in spite of a vast amount of research 
and discussion, still in an unsatisfactory condition, 
it will, nevertheless, be advisable to consider them 
briefly : first, because they are such prolific sources 
of pain, and, secondly, because of the tendency, at 
present discernible in some quarters, to ascribe im- 
portance to a neuropathic principle as an element 
in their development. 

Rheumatic fever, as is plainly enough indicated 
by its clinical history, is an acute febrile affection of 
non-contagious character, the most evident charac- 
teristics of which are the development of multiple 
arthritis and a disposition to invade the heart. 

There are three conspicuous theories with regard 
to the nature of the affection. The first of these 
affirms that the changes in the joints are due to the 
presence of a specific microbe ; the second, that they 
are the outgrowth of defective metabolism, — i.e., the 
70 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 71 

presence of pathological material in the system, due 
to derangement of assimilation ; and the third, that 
the arthritis is attributable to a primary disturbance 
of the nervous system, culminating either in im- 
pairment of metabolism or in local trophic changes 
which are the result of the primary effects of cold 
upon the nervous system. 

It is noteworthy that by some the morbid product 
due to this defective metabolism is believed to be 
lactic acid. 

In gout, as all are aware, we have to do with a 
disease which is characterized by the appearance at 
irregular intervals of acute arthritis, with subsequent 
gradual deposit of urate of soda within and in the 
vicinity of the joints, and by the over-production, or 
defective elimination, of uric acid. 

Concerning the causation of gout, three theories 
are likewise worthy of mention. 

The first of these — the so-called uric acid theory 
— has obtained the widest currency in the profes- 
sion. According to its teuets, there is an increased 
accumulation of uric acid in the blood, attributable 
either to inadequate elimination or over-production. 

The advent of the acute attack is believed to be 
directly attributable to this morbid accumulation, 
and the same may be said of the nervous irritability, 
depression, and gastric derangements which are the 



72 PAIN. 

common precursors of the acute inflammation of 
the joints. 

A second theory is that of Ord, who believes that 
the changes in the joints are directly due to a degen- 
erative proclivity of the tissues themselves. This 
liability to degenerate may be either congenital or 
acquired. I do not think that there is much justi- 
fication for this assumption, since dietetic precautions 
usually prevent the local degeneration. 

Finally, we have the nervous, or rather neuro- 
humoral, theory of the disease as advocated by 
Duckworth and others. This theory assumes, on 
the one hand, the existence of a neurosis, and on 
the other, a tendency to lethargic or defective meta- 
morphosis. 

So much, then, for the diversity of opinion which 
exists regarding the ultimate pathology of the two 
affections. But while these differences are striking 
enough in themselves to discourage one from at- 
tempting to elaborate a scientific method of treat- 
ing the disease, it must nevertheless be admitted 
that quite a good deal has been accomplished within 
the last few years — largely in an empirical way — 
for the more effective management of both dis- 
orders. This may be said with especial emphasis 
of the painful symptoms which are so striking a 
feature of both diseases. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 73 

It is hardly necessary to enter upon a lengthy 
description of the regular forms of gout and rheu- 
matism : the metatarso-phalangeal pain and redness, 
confined, as a rule, to one of the great toes, the 
premonitory gastric symptoms, the sudden onset of 
the pain, — usually at night, — and the moderate chil- 
liness and fever, are quite characteristic of the 
former; whereas the presence of acute inflamma- 
tion and pain in several joints is decided evidence 
of the rheumatic nature of the trouble. 

But while these typical manifestations of both dis- 
eases are known to every physician, the irregular 
modes of expression have commonly received, I 
believe, much less attention than they deserve. 
These observations are especially applicable to 
"concealed" or "irregular" gout, which is certainly 
often responsible for the development of nervous 
symptoms, and notably neuralgia. Again, the 
chronic interstitial nephritis which frequently de- 
velops in severe cases of gout is responsible, no 
doubt, for the advent of some of the milder forms 
of nervous disturbance. Eventually, as in ordinary 
cases of contracted kidney, death may occur from 
cerebral hemorrhage (or embolism, where there is 
concurrent heart-trouble) or uraemia. One of the 
most frequent cerebral manifestations, commonly — 
and probably justly — ascribed to the morbid accu- 



74 PAIN. 

mulation of uric acid, is headache ; which, though 
usually of the less vehement type, may exceptionally 
manifest great severity. 

With the occurrence of renal troubles and arterio- 
sclerosis, the cerebral disturbances may be much 
increased in severity and persistency. It is self- 
evident that symptoms of this kind may readily be 
misinterpreted where the question of causation is 
involved; so that nothing is more common than 
to find these patients wandering about from one 
medical practitioner to another, without obtaining 
any considerable benefit. The chief difficulty in 
such cases is usually a failure on the part of the 
physician to appreciate the true chronology of the 
various symptoms. 

Too great pains, then, cannot be bestowed upon 
the framing of a correct diagnosis, without which 
there is scant probability of our suggesting thera- 
peutic measures of much utility. 

Treatment. — Little need be said of the manage- 
ment of the acute phases of rheumatism, since 
every practitioner is doubtless familiar with essen- 
tials. As all are aware, two methods of treatment 
are especially conspicuous; the one involving the 
copious use of salicylic acid, the other the admin- 
istration of alkalies. The use of salicylic acid is 
especially satisfactory, since the pains yield to its 



75 

influence with remarkable promptness. On the 
other hand, alkalies are more liable to prevent 
the occurrence of secondary heart-trouble; and 
besides this, it is a remarkable fact that patients 
who have been treated with them are usually able 
to leave the hospital and attend to their affairs 
much sooner than those who have taken salicylic 
acid alone. It is evident, then, that each plan of 
treatment has its own special advantages; and for 
this reason I prefer the mixed treatment, or that 
which involves the use of both acid and alkalies. 

The salicylate of sodium may be used in twenty- 
grain doses every hour for the first six or seven 
hours. The patient may then be instructed to 
discontinue all medicine for the next eight hours. 
After the lapse of this interval of rest he may be 
given the iodide or citrate of potash in twenty- or 
thirty-grain doses every three hours, until the saliva 
becomes alkaline. "Whether, as stated by some, this 
recommendation originated with Fenwick, I do not 
know; but I can certainly vouch for its efficacy, 
especially when combined with the use of phenace- 
tin and salol. The local application of the oil of 
wintergreen by the aid of lamb's wool or absorbent 
cotton will naturally suggest itself, and the same 
may be said of the use of liniments, blisters, and 
sinapisms. 



76 PAIN. 

When recovery has taken place, great caution 
should be exercised in the use of stimulants; and 
indeed, all foods the ingestion of which is liable to 
add to the acidity of the blood should be avoided as 
much as possible. This is all the more necessary 
since those who have had one visitation, far from 
having obtained immunity, are more than ever liable 
to be attacked by the disease. 

Very much the same class of recommendations 
are applicable in the management of gout, whether 
of the common, acute type or of the concealed 
variety. 

When the great toe is very painful, the entire 
limb should be elevated and the painful joint 
wrapped in wool or treated with hot applications. 
Should the pain refuse to yield to local measures 
of any kind, it may be necessary to invoke the aid 
of analgesis ; and, if the patient be of a nervous, 
irritable disposition, the best way out of the diffi- 
culty will be to give him a moderate dose of mor- 
phine. 

Colchicum in twenty- or thirty-minim doses, either 
of the tincture or wine, may be given every four 
hours ; for, though much less used at present than 
before the introduction of salicylic acid, this remedy 
exerts an undoubted influence in reducing the red- 
ness and abating the pain in the joint. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 77 

Mineral waters of various kinds have been found 
useful in gout. Among those commonly recom- 
mended are the waters of Vichy, Carlsbad, Sara- 
toga, and White Sulphur Springs. 

When the disease becomes chronic, warm baths — 
and notably those of Wiesbaden, Teplitz, Carlsbad, 
Aix, and Ems — may be prescribed with advantage. 

It has become fashionable of late to prescribe a 
special diet for those afflicted with gout; and, 
though nominally founded on the theoretic exigen- 
cies of the disease, a glance will reveal discrepancies 
of opinion which it is hard to reconcile by even the 
most adroit sophistry. The chief desideratum, after 
all, is to reduce the quantity of food ingested, — a 
precaution which of itself cannot fail to diminish 
the dangers of defective metabolism and consequent 
accumulation of uric acid. As may readily be in- 
ferred, both the acid and saccharine foods are to be 
excluded as far as possible; and, without burden- 
ing the mind of the patient too much with details, 
he should be informed at once that the success of 
treatment is largely a question of his own volitional 
ability. 

In concluding these brief observations on the 
management of rheumatism and gout, it will be 
well to consider a remedy which has been much 
written about of late in connection with its reputed 

7* 



78 PAIN. 

quality as a solvent of uric acid. I allude, of course, 
to piperazin (C 4 H 10 I^ 2 ). The routine quantity of 
fifteen grains pro die in divided doses is applicable 
in the cases characterized by moderate uric acid 
accumulations, whereas in severe and obstinate 
rheumatism this amount may be much exceeded. 
The remedy is quite soluble in water, and forms an 
alkaline but non-caustic solution. Its power of dis- 
solving uric acid has been shown, by the researches 
of Schmidt and Biesenthal, to be much greater than 
that of sodium carbonate, lithium carbonate, or 
borax solution. In dissolving uric acid, piperazin 
combines with this body, forming urate of pipera- 
zin, which in turn is exceedingly soluble in water. 
This piperazin urate is, moreover, much more 
readily diffusible through animal membranes than 
the lithium and sodium urates. All this is equiva- 
lent to stating that a piperazin solution is able to 
penetrate to the most remote tissues, dissolve the 
uric acid which may be deposited there, and finally 
escape in the form of urate of piperazin by way of 
the kidney. Piperazin is best given in solution in 
order to insure rapid absorption. It may also be 
exhibited with great effect, in cases accompanied by 
much pain, in combination with an equal dose of 
phenocoll, the analgesic properties of which are well 
known. To carry out this idea in a practical way, 



79 

a phenocoll-piperazin water has been prepared, each 
pint of which contains eight grains of phenocoll and 
eight grains of piperazin. Two or three pints of 
this water may be drunk daily without the least 
unpleasant consequences. 

Space will not permit a more extended discussion 
of details, which properly belong in special mono- 
graphs and treatises on general medicine. One of 
the most recent and practical of the former is Dr. 
Satterlee's little book, which will be found to abound 
in helpful suggestions. 



CHAPTER V. 

PAINS WHICH HAVE THEIR SEAT IN THE STRUCTURES CON- 
TAINED WITHIN THE CAVITIES OF THE BODY — INTRA- 
CRANIAL pains (headache) — "spinal" (medullary) 

PAINS — ABDOMINAL AND THORACIC (VISCERAL) PAINS. 

The pains associated with inflammatory changes 
in the nerves which supply the exterior of the body 
having been previously considered, it now remains 
to examine in a general way those pains that have 
their seat in the structures contained in the various 
cavities of the body. Prominent among such pains 
are what are currently known as headaches, all or 
most of which — if we except those due to syphilitic 
periostitis of the cranium and disease of the internal 
ear — are attributable to intracranial causes. 

These pains which are directly or indirectly refer- 
rible to disturbances within the cranial cavity are 
characterized by the presence of more or less mental 
irritability, prostration, and sensory hyperesthesia, 
and less frequently by vertigo, nausea, and vomiting. 

Various attempts to classify these intracranial 
pains have been made; but as our knowledge of 
80 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 81 

their causation is still incomplete, all such efforts 
are necessarily imperfect. 

The following nomenclature, which is a slight 
modification of that adopted in my book on " Head- 
ache and Neuralgia," is perhaps open to as little 
criticism as any. 

Pains which have their Seat within the Cranial 
Cavity — Intracranial Pains — Headache. — Anaemic 
headache, as its name implies, is proximately due to 
a deficiency of the blood-supply within the cranial 
cavity. It is an almost invariable accompaniment 
of general anaemia and chlorosis, and hence young 
persons, and more especially girls, are particularly 
subject to its attacks. Any morbid condition which 
culminates in a reduction of the normal amount of 
blood in the system may cause it. Hence it may 
be associated with widely-different diseases. De- 
bility, then, is the great prerequisite to its occur- 
rence. 

The more important symptoms of this anaemic 
form of headache are clawing pains at the vertex, 
vertigo evoked by suddenly changing from an erect 
to a recumbent position, increased compressibility 
of the carotids, facial pallor, fatigue upon slight 
exertion, mental depression, hyperesthesia of the 
special senses, particularly sight and hearing, droop- 
ing of the eyelids, drowsiness during the day and 



82 PAIN. 

sleeplessness at night, and finally, pronounced car- 
diac weakness, 

Hyperaemic headache, the opposite condition of 
that previously described, is due to an increase in 
the arterial blood-tension with accompanying relax- 
ation of the cerebral capillaries. Its characteristic 
symptoms are sensations of fulness in the head ; 
vertiginous attacks appearing spontaneously or fol- 
lowing changes of position ; morbid irritability, as 
exemplified by sudden anger upon trivial provoca- 
tion; throbbing of the carotids; and attacks of 
palpitation. 

Nervous or cerebral headache is sometimes hemi- 
cranial in type, but more frequently there is little 
that is distinctive about it either in quality or lo- 
cation. Sometimes the pain is predominantly felt 
in the forehead, vertex, or occiput; whereas, in a 
smaller percentage of cases, it evinces a predilec- 
tion for the temple, or, as already mentioned, for 
one-half of the head. 

Whatever the precise location of the pain may 
be, however, there is always more or less mental 
irritability, and usually also nausea and vertigo. 
Visual and auditory hyperesthesia are likewise 
characteristic and quite constant accompaniments. 

The cerebro-hypersemic and cerebro-ansemic forms 
of headache represent merely modifications of the 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 83 

nervous type of head-pains, the alterations in the 
clinical picture being due, or largely due, to the 
presence of a marked degree of circulatory dis- 
turbance. 

The neurasthenic type of headache is usually 
much like that just described as " nervous" head- 
ache. There are, however, occasional deviations in 
type, — deviations which vividly recall the symptoms 
more particularly described under the head of 
anaemic headache. Then, too, there are also present 
in varying degrees of intensity the well-marked 
phenomena of nervous exhaustion, — the so-called 
neurasthenic symptoms; and these, taken in con- 
junction with the general history of the case, will 
serve to facilitate diagnosis. 

The lymphatic or bilious headaches include the 
various head-pains which are obviously due to some 
peripheral source of irritation, — to some cause origi- 
nating outside the cerebro-spinal canal. While 
hemorrhoids, ovarian disease, and uterine derange- 
ments may give rise to it, its most prolific cause 
must be sought for among the manifold disturbances 
of the organs of digestion. 

It is highly probable, however, that, inasmuch as 
these disorders may exist in the absence of all head- 
symptoms, a certain neurotic predisposition is es- 
sential, in order that the peripheral disturbances 



84 PAIN. 

shall culminate in intracranial derangements of a 
painful character. In consonance with this opinion, 
we find that impressionable young people, and more 
especially girls, are subject to this form of headache. 

The symptomatology presents nothing of especial 
interest, and its principal features are soon told. 
There are local pains of a constant, heavy, clawing 
character ; yellow appearance of the skin ; stomachic 
discomfort; general malaise and depression; and 
not infrequently attacks of giddiness, which are 
erroneously ascribed by the subject to cerebral 
causes, but which primarily, at least, are due to 
irritation emanating from the stomach. 

In the toxic form of head-pain we have — in so far 
as the causation is discoverable — to do with some 
change in the normal constitution of the blood, 
due either to the evolution of some toxic condition 
within the organism itself, or to the introduction of 
some poisonous agent from without. Uraemia af- 
fords an excellent example of the one, and chronic 
alcoholism of the other, mode of poisoning. Let 
the method of poisoning be what it may, its results, 
a toxic condition of the blood and consequent irri- 
tation of the nervous system, are the same. 

The pains have nothing especially characteristic 
about them, when considered collectively. Some- 
times they may be dull and heavy, as we find them 



PATHOLOGICAL, CLINICAL. 85 

among brass-workers, or they may be splitting, as 
in the headache of syphilis. 

In all cases permanent relief is contingent upon 
removal of the poison from the system. This is not 
possible where the source of the poison is found in 
some organic alteration of the viscera, as in Bright's 
disease. It is, however, more readily attainable 
when the toxic agent has been introduced from 
without, as in syphilis and lead-poisoning. These 
are, however, matters which will be treated more in 
detail in the chapter especially devoted to the treat- 
ment of pain. 

The lesions which are largely responsible for 
organic head-pain are syphilis and the various 
kinds of tumors, disease of the cerebral arteries, 
tuberculosis, cerebral softening, bony formations 
within the cranial vault, and meningitis. Organic 
disease is, however, by no means as frequent a 
cause of headache as might be imagined from the 
percentage of gross cerebral lesions. Nor is the 
diagnosis of this variety of headache always an 
easy matter; for, in the first place, there may be 
nothing especially characteristic about the pain ; and, 
secondly, more or less profound organic changes 
may be present without evoking painful manifes- 
tations of any kind. 

Speaking in a general way, it may be said that 

8 



86 PAIN. 

headaches due to organic disease of the brain are 
usually more or less continuous in character, and 
are referred to a circumscribed portion of the cra- 
nium. Concomitant disturbances of sensation and 
motion, assuming the form either of local spasms, 
paresis, or impairment of vision, or combinations 
of all of them, may help to clarify the diagnosis; 
but these are by no means always present. Some- 
times the loss of muscular power is very gradually 
accomplished; and under these circumstances ver- 
tigo, impairment of memory, and loss of visual 
efficiency (optic neuritis) assume a prominent place 
in the symptomatology. 

Headache accompanied by epileptic phenomena, 
facial paralysis, and disturbances of speech, occur- 
ring at the period of adolescence, may, in the ab- 
sence of negative testimony, be ascribed to syphilis. 
In such cases copious mercurial inunctions and the 
administration of large doses of the iodides are 
sometimes followed by a reduction and eventual 
disappearance of the symptoms. 

Unfortunately, such a happy issue is rather the 
exception than the rule, and is only to be anticipated 
in cases with undoubted syphilitic antecedents. In 
the vast majority of cases of organic headache we 
are indeed quite unable to extricate the patient 
from his deplorable plight. Occasionally, it is true, 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 87 

cerebral surgery has been able to accomplish some- 
thing ; but this field of the art is necessarily limited : 
first, by the imperfections of diagnosis ; secondly, by 
the fact that a large proportion of cerebral growths 
are malignant; and, thirdly, because extensive intra- 
cranial extirpations mean a commensurate oblitera- 
tion of important cerebral organs. No amount of 
sophistry can modify the situation in this regard 
one whit. 

In a large proportion of cases, then, treatment is 
purely palliative, and consists for the most part in 
the amelioration of the pains by opiates. 

Pains which have their Seat within the Thoracic 
Cavity. — The majority of pains located within the 
thoracic cavity are due either to the presence of 
neoplasms or aneurism, or they occur in the course 
of acute affections of the heart or lungs. The 
more detailed consideration of these pains belongs 
without doubt in the domain of general medicine. 
There is, however, one variety of precordial pain 
which may properly be considered in a work of this 
kind; I refer to the affection variously known in 
the books as angina pectoris, stenocardia, nervous 
heart-pain, or cardiac neuralgia. Now, it is a well- 
known anatomical fact that the superior and infe- 
rior cardiac branches of the vagus join the cardiac 
branches of the sympathetic to form the cardiac 



88 PAIN. 

plexus. In accordance with current physiological 
opinion, three kinds of fibres are assumed to exist 
in this plexus : those whose stimulation accelerates 
the heart-beat; those whose stimulation retards the 
heart-beat; and, finally, those whose function is 
the conveyance of sensory impressions from the 
heart. 

Inasmuch as pain is the cardinal symptom of 
angina pectoris, the affection in its idiopathic form 
is commonly regarded — and it must be confessed 
with considerable reason — as a neurosis of the pneu- 
mogastric nerve. Some participation of the sympa- 
thetic system of nerves is also probable, as Lance- 
reaux and others have been able to show from the 
results of a number of autopsies. 

A sharp differentiation of this, the true or idio- 
pathic form of the affection, as contrasted with the 
angina-like pains due to organic disease of the heart, 
must of course be maintained. Among the cardiac 
lesions which most frequently give rise to pseudo- 
angina, if I may so call it, are valvular disease, fatty 
degeneration of the muscle, and disease of the cor- 
onary arteries. 

• The clinical phenomena of angina pectoris have 
been described in the text-books over and over again 
during the last century, so that all practitioners are 
doubtless well able to recognize the affection. The 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 89 

most obvious symptoms are a severe pain occurring 
in paroxysms in the neighborhood of the left nipple, 
a feeling of impending dissolution, profuse cold 
perspiration, and occasional dyspnoea. 

As a rule, there is no aura whatever, the seizure 
taking place without warning by day or night, re- 
gardless of all ascertainable physical or psychical 
incentive. Where there is absence of organic 
changes in the heart, there is complete cessation of 
all symptoms during the intervals, the patient de- 
claring at such times that he feels as well as ever. 
Under these circumstances, when we have appar- 
ently to do with a neurosis of the sensory filaments 
of the heart (" vagus neurosis"), the danger to life 
is practically nil. When, however, atheroma of the 
coronary arteries or some other grave cardiac lesion 
is present, the outlook is threatening, death during 
a paroxysm being a frequent sequence. 

The really efficacious remedies at our command 
for combating the paroxysm are few in number 
and well known to the profession. The inhalation 
of from four to eight drops of the nitrite of amyl 
is generally regarded with favor; and those who 
are the victims of inveterate angina should be told 
to carry about a few of the well-known hollow glass 
beads, each of which contains a medium dose of 
the drug. One or more of these may be broken 



90 PAIN. 

upon a handkerchief and inhaled as soon after the 
inception of the attack as possible. 

Hypodermic injections of morphine and inhala- 
tions of chloroform or ether have, in my experience, 
often rendered good service. All kinds of remedies 
have been exhibited during the intervals with a 
view to aborting the attacks and eventually ob- 
taining exemption from the difficulty. It must be 
confessed, however, that the results thus far ac- 
complished are not brilliant. Digitalis, spartein, 
strophanthus, and indeed the whole group of 
cardiac stimulants have been tried, and the same 
may be said of the so-called alteratives. Nothing, 
however, save disappointment has come of all this. 

Speaking generally, it may be said that the fac- 
tors which are likely to engender a predisposition 
to neuritis are those which are most carefully to be 
avoided. Among these tobacco has been assigned 
— and rightly so, it would seem — a prominent posi- 
tion. And yet many cases of idiopathic angina 
occur among women, — cases in which a subsequent 
autopsy has failed to reveal any organic disease 
which might reasonably be supposed to account for 
the symptoms, and in which, moreover, the entire 
clinical history may be absolutely negative in so far 
as it affords a clue to questions of causation. 

The whole matter of etiology, then, in so far as 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 91 

so-called functional or idiopathic cases are con- 
cerned, is enveloped in more or less obscurity. 

Pains which have their Seat in the Cavities of 
the Abdomen and Pelvis. — To enumerate and dis- 
cuss even a small number of the pains which are 
intimately associated with the development of acute 
diseases or neoplasms would overtax the limits of 
the present publication. Indeed, the more detailed 
consideration of such pains is in the nature of 
things intimately connected with that of the dis- 
eases themselves, of which the pains are but one of 
the modes of expression; hence the whole subject 
belongs in the domain of general medicine, and 
there I shall leave it. 

Let me add, however, that in a subsequent por- 
tion of this work I shall offer a few observations 
on the practical management of pain the source of 
which is located in one of the large cavities of the 
body, and is therefore inaccessible to local means of 
attack. 



CHAPTER VI. 

THE DIAGNOSTIC VALUE OF PAIN. . 

It has already been shown that the peripheral 
(sensory) nerves afford the only routes by which 
painful impressions are transmitted to the cerebro- 
spinal axis, and thence to the centres of conscious 
perception. Moreover, it is equally clear that the 
greater the supply of such filaments to a part, the 
greater must necessarily be the susceptibility of 
that region to pain-provoking influences. Herein 
lies the explanation of the striking variations in 
the intensity of painful sensations emanating from 
the different tissues. 

Every physician is cognizant of this immense 
diversity of sensibility as a matter of practical 
experience, but few pause to consider the simple 
anatomical fact which lies at the basis of the 
phenomenon. The sensibility of bone (even if we 
include the periosteum) is not equal to that of the 
skin ; nor is that of cartilage comparable with that 
of the muscle. 

The varying degrees to which the sensory nervous 

92 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 33 

system has been developed in these tissues are suffi- 
cient, then, to account for quantitative differences 
in the pains. 

But variations in the abundance of the sensory 
nerve-supply, while certainly the main factor in 
determining the differences in pain-susceptibility 
of the tissues, do not give rise to qualitative 
modifications. 

These differences in the kinds of pain which 
we feel are far more likely to be contingent upon 
the nature of the pathological process prevailing 
in the tissue. At all events, this seems to hold 
good with regard to the nerves of common sensa- 
tion. 

Another important fact is, that the mind usually 
refers the painful sensations perceived by it to the 
seat of irritation (disease). The exceptions to this 
rule will be considered later. Thus it happens that 
one of the greatest services, if not the very greatest, 
which pain renders the clinician consists in its abil- 
ity to point out the seat of trouble. The result of 
this is that, even when the pain itself is not suffi- 
ciently characteristic to admit of our deriving from 
it exact inferences as to the nature of the disease, 
our attention is, nevertheless, at once drawn to the 
seat of trouble ; investigation reveals a number of 
collateral symptoms; and these, in conjunction 



94 PAIN. 

with the pain, enable us to form an exact diag- 
nosis. 

Regarded from this stand-point alone, it is almost 
impossible to over-estimate the diagnostic value of 
pain. The wonder is that so little attention has 
been accorded it in current works on diagnosis. 

In view of the importance of the subject on the 
one hand, and the paucity of helpful literature on 
the other, I trust that by citing some of the more 
important examples of the helpfulness of pain in 
diagnosis I shall not trespass unduly upon the 
patience of the reader. 

Pains about the Head, including the Bye and 
Ear. — In the headache of anaemia there is present 
quite a characteristic kind of pain, — the clawing 
sensation at the vertex, with concomitant vertigo 
and drowsiness, and morbid susceptibility to light 
and sound. In the opposite condition of cerebral 
engorgement the pain is more diffuse, and is ac- 
companied by a feeling of fulness and constric- 
tion. 

Severe unilateral pain, with photophobia and 
gastric derangements, constitute the more striking 
features of megrim. 

Pain over the orbit is also quite characteristic 
of the headache due to malarial poisoning (" brow 
ague," supraorbital neuralgia). Of this type of 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 95 

headache we have already had something to say 
when discussing the various forms of neuralgia, — 
that phase of pain in which the symptoms are prac- 
tically restricted to the ramifications of one or more 
nerve-stems. 

Syphilis, too, frequently gives rise to a very 
characteristic kind of head-pain, — the well-known 
" splitting, boring" headache. 

Again, in the severe headaches due to tumors 
and other organic lesions located within the cra- 
nium, the pain is apt to be constant and more or 
less confined to definite regions of the cranium. 

This reference of the pain by the patient to cer- 
tain areas cannot, however, be regarded as posi- 
tive proof of the correct localization of the central 
lesion ; for it has frequently happened that a sub- 
sequent post-mortem examination has shown the 
conceptions of the subject to have been entirely at 
fault, the lesion being found in quite a different 
portion of the intracranial structures. In addition 
to the severe pain, organic headache is frequently 
accompanied by more or less profound derange- 
ments of sensation and motion. These disturbances 
usually assume the form of spasms, paresis, and 
visual impairment (optic neuritis, paralysis of ex- 
trinsic ocular muscles, etc.). 

Again, vertigo, derangements of memory, and 



96 PAIN. 

progressive loss of muscular power are the con- 
comitant factors in other cases. 

Some of the pains found in and about the eye 
are of the highest importance from a diagnostic 
stand-point, since, in conjunction with other symp- 
toms, they enable us to detect the presence of 
severe disease of the eyeball in time to act effect- 
ively against it. 

This is especially true of acute glaucoma, panoph- 
thalmitis, and plastic iritis. 

In acute glaucoma there is present severe pain 
in the eyeball, with concomitant dilatation of the 
pupil, shallow anterior chamber, increased tension 
of the eyeball, impairment of vision, photophobia, 
redness of the eye, and lachrymation. The pain is 
hemicranial in type, and may involve not only the 
area supplied by the supraorbital nerve, but also 
that to which other branches of the fifth nerve are 
distributed. 

The pain of panophthalmitis, on the other hand, 
is usually less intense ; the cornea is opaque from 
ulceration or inflammatory changes, which obscure 
the pupil and iris; chemosis is present; and there 
is much swelling of the eyelids and protrusion of 
the eyeball. 

In plastic iritis the pain may be slight or severe ; 
the pupil is contracted ; the eyeball is red, the iris 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 97 

discolored ; and, on instilling a mydriatic, the pupil 
fails to dilate regularly on account of the presence 
of adhesions. On the other hand, serous iritis pre- 
sents somewhat different appearances. There is 
pain, but it is not vehement ; the pupil instead of 
being contracted is dilated; the anterior chamber 
is abnormally deep, and the posterior aspect of 
the cornea is covered with small spots of exuda- 
tion. 

Some of the pains associated with severe ear-dis- 
ease are quite significant. 

Thus, in mastoiditis (abscess of the mastoid cells) 
there is pain of varying intensity, which is most 
acutely felt directly behind the ear. Inspection of 
this locality, when the disease is at all advanced, 
reveals swelling and redness ; while even moderate 
pressure demonstrates the existence of exquisite 
local tenderness. 

It is self-evident that the prompt recognition of 
the true significance of this state of affairs is of the 
utmost importance, since it renders early operative 
interference possible, thus probably averting a fatal 
meningitis. In acute otitis media the pain in the 
ear is vehement, is increased by the recumbent 
posture, and usually ceases on operative or sponta- 
neous perforation of the membrana tympani. That 
the pain is due to intratympanic pressure is revealed 
e g 9 



98 PAIN. 

by the bulging of the red and swollen drum towards 
the meatus. 

In addition to these pains, there is an earache, 
which is obviously due to neuritis of the sensory 
filaments of the ear. 

Carious teeth, post-pharyngeal abscess, and caries 
of surrounding bony structures may give rise to this 
kind of ear-pain. 

Paina Eeferrible to Disease of the Organs within 
the Thorax. — Besides the pains which are associated 
with the extensive organic changes present in pul- 
monary cancer and phthisis, aneurism of the ascend- 
ing aorta and mediastinal abscess, there are others 
which serve as warnings in a number of acute affec- 
tions of both heart and lungs. Thus, in acute 
pleurisy, during the dry stage, we have local pain 
with the well-known friction sound and impairment 
of movement of the chest-wall. Later, in the stage 
of effusion, there is the usual dulness on percussion 
over the accumulated fluid; and in severe cases, 
displacement of the liver or heart. 

Again, in acute pneumonia the thoracic pain asso- 
ciated with fever, cough, and the cherry-colored 
expectoration constitute an eminently characteristic 
group of symptoms. The diagnosis should not, 
however, be hastily made, the crepitant rales, the 
dulness with blowing respiration, increased vocal 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 99 

fremitus, and bronchophony yielding the necessary 
confirmation. 

Pain in the chest is also present in both acute and 
chronic pulmonary phthisis. In the former affec- 
tion we find it associated with the usual premoni- 
tory chill, fever, anorexia, emaciation, and night- 
sweats; to which more or less irregular physical 
symptoms — dulness over a tubercular deposit, cav- 
ernous breathing, and moist rales — may be added. 

Precordial pain is a more or less significant 
symptom in affections of the heart and its mem- 
branes. Thus, in both acute pericarditis and endo- 
carditis there is more or less pain. In the former 
affection it is associated, at first, with a more or less 
well marked friction sound, and later, as the peri- 
cardium becomes distended with fluid, with an 
increase in the area of percussion dulness. The 
characteristic pyramidal shape of this area of dul- 
ness, while the patient is standing, is one of the 
familiar observations of the sick-room. 

In endocarditis the pain, while severe at times, 
is accompanied by a blowing instead of a friction 
sound; and later there is usually little or no in- 
crease of percussion dulness. 

Finally, in all valvular diseases, especially aortic, 
in fibroid disease of the heart, in thrombosis of 
the pulmonary artery, and in cardiac affections of 



100 PAIN. 

purely functional character, there is more or less 
pain. 

Pain associated with Disease of the Organs con- 
tained in the Abdominal Cavity. — In cancer of the 
stomach the pain is gnawing in character, and is 
felt with special intensity in the epigastrium. Much 
the same kind of pain is present in cancer of the 
pancreas, a fact which has often given rise to errors 
in diagnosis. It would lead us too far were we to 
enter into the details involved in the symptoma- 
tology of abdominal troubles ; that is a task which 
we gladly assign to the systematic treatises on in- 
ternal medicine. On the other hand, it may be of 
interest to recall the more important derangements 
of the abdominal organs in which pain of varying 
degrees of intensity is a noteworthy symptom. We 
have already spoken of cancer of the stomach and 
pancreas, both of which are accompanied by more 
or less continuous and severe pain; but, in addi- 
tion to these, pain is conspicuous in a large array 
of other diseases of the abdomen. Prominent 
among these are the following: gall-stones, the 
passage of which produces severe epigastric pain 
which may be mistaken at first for colic. The 
location of the pain in the epigastrium, the pres- 
ence of jaundice, the severe vomiting, and the com- 
paratively brief duration of the paroxysm serve, 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 101 

however, to characterize the latter sufficiently for 
diagnostic purposes. 

Pain in the abdominal region is also a more or less 
striking feature of irritant poisoning, ulcer of the 
stomach, — especially manifest shortly after eating, — 
suppressed gout, acute gastritis, — likewise evident 
after the ingestion of food, — colic, cholera, enter- 
itis, intussusception, the gastric crises of locomotor 
ataxia, lead colic, peritonitis, perityphlitis, organic 
diseases of the liver, aneurism, organic disease, and 
obstruction of the intestine. In the region of the 
pelvis we have, moreover, the characteristic pain 
which radiates from the ovary in a downward direc- 
tion, and may extend, and usually does extend, to 
the anterior aspect of the thigh. This pain is com- 
monly traceable to more or less severe disease of the 
ovaries, tubes, or both. It is, however, an unfortu- 
nate circumstance that extirpation of the diseased 
ovaries and tubes does not always result in a per- 
manent removal of the neuralgia. It would seem 
that in such cases the irritable condition of the 
nerves involved is perpetuated by some extraneous 
factor as yet unknown to us. More or less severe 
pain in the region of the 'pelvis is also associated 
with cancer of the uterus, pelvic abscess, pelvic 
cellulitis, vesical calculus, dysmenorrhea, acute and 
chronic endometritis, pelvic hematocele, fibroid dis- 

9* 



102 PAIN. 

ease of the uterus, cystitis, pelvic peritonitis, and 
the various displacements of the uterus. 

In concluding this brief summary of the more 
important pains associated with diseases of the 
organs of the abdominal cavity, we must not forget 
those eminently characteristic and terrible pains 
which are associated with the passage of a stone of 
considerable size and roughness from the pelvis of 
the kidney through the ureter. 

These pains shoot from the lumbar region, follow 
the course of the ureters, and may even extend as 
far as the testicles. They constitute the so-called 
"renal colic," and are by far the most striking 
feature of nephrolithiasis. The duration of these 
pains, as is well known to all physicians of experi- 
ence, is contingent upon the length of time the 
stone remains incarcerated in the ureter. Some- 
times a few hours suffice for the completion of the 
descent of the stone into the bladder; whereas at 
others several days, during which the patient is 
kept as much as possible under the influence of 
opiates, are necessary to complete the operation. 

Pain associated with Organic Diseases of the 
Nervous System. — Pain is in greater or less degree 
a characteristic concomitant of most organic af- 
fections of the nervous system, and particularly 
those of the spinal cord. This is strikingly illus- 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 103 

trated in acute spinal meningitis, where the pains 
in the back and along the course of the principal 
nerve-trunks constitute, with the distortions of 
the limbs and opisthotonus, due to the spasm of 
the muscles, a most characteristic picture. In 
the various inflammatory conditions of the cord, 
involving in greater or less degree the sensory 
mechanism, pain is a symptom of considerable im- 
portance. The terms acute, subacute, and chronic, 
as applied to myelitis, relate more particularly to 
the variable length of time required for the develop- 
ment of the symptoms ; unusual vehemence of the 
pains and rapid evolution of the paralysis of the 
muscles, especially those of the lower extremities, 
as in transverse myelitis, coupled with bed-sores 
and bladder disturbances, being characteristic of 
the acute phase of the disease. The location of 
the pains will, of course, be contingent upon the 
seat and size of the central lesion; so that in a 
general way, it may be said, that the wider the 
distribution of the latter the greater will be the 
extent of the painful area. 

Headache, paresthesia, and lancinating pains in 
the limbs are comparatively rare in multiple cere- 
brospinal sclerosis, but are characteristic of loco- 
motor ataxia. In the latter disease, the so-called 
lightning pains, which shoot down the limbs, con- 



104 PAIN. 

stitute with the stamping gait, and other evidences 
of incoordination, a complex of symptoms so char- 
acteristic as to be hardly mistakable for any other 
disease. Tumors of the spinal cord do not, as a 
rule, give rise to marked sensory irritation in the 
beginning. After a time, however, when their 
location in the spinal cord is favorable, their pres- 
ence is announced by the appearance of shooting 
pains, paresthesia, and, eventually, anaesthesia; in 
short, by the series of phenomena known in the 
books as " root-symptoms." 

Still later, the further compression of the cord, 
in consequence of the growth of the neoplasm, is 
shown by loss of power in the muscles, culminating 
at length in complete paralysis. 

The resemblance of these symptoms, both in 
character and manner of evolution, to those of 
diffuse chronic myelitis, cannot have escaped the 
reader. Indeed, this similarity in the phenomena 
of the two diseases is so great as in many instances 
to preclude the differentiation of medullary tumor 
from transverse myelitis. Sudden exacerbations of 
pain and general irregularity of the symptoms are 
believed by some to be an indication of tumor ; but 
little reliance can be placed upon this assumption, 
or upon that which perceives in irregularity of de- 
velopment a token of syphilis. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 105 

We may note in passing that the condition in- 
duced in the cord by pressure of the tumor is 
known as compression myelitis, and may likewise 
be engendered by caries and various injuries of the 
spine. As a matter of course, the intensity and 
rapidity of evolution of the pains and other symp- 
toms will depend very largely upon the nature and 
extent of the injury or morbid change to which the 
myelitis is due. 

As may readily be inferred from the character of 
the central lesion, pain is but a subordinate element 
of poliomyelitis anterior acuta, the paralysis and 
muscular atrophy being the significant features. It 
likewise occupies the same position in spastic spinal 
paralysis, the weakness in the legs, observed in the 
beginning, and the spasmodic condition of the mus- 
cles subsequently developed, with the inevitable 
sequences, — exaggerated tendon reflexes and ankle- 
clonus, — constituting the characteristic symptom 
group. Elsewhere will be found a description of 
the more significant pains due to organic changes 
in the brain, so that the subject need not be re- 
opened. 

Before terminating the discussion of the diag- 
nostic relations of pain, let me say that the pains 
felt in the muscles are sometimes significant. Thus, 
in trichinosis, the muscular pains occurring at the 



106 PAIN. 

end of the second week or later are due to the 
myositis engendered by the parasites. It is true 
that when the number of trichinae is relatively 
small the pains may be so slight as to remain 
almost unperceived. "When, however, the invasion 
is extensive, the chain of symptoms is most char- 
acteristic. The muscles become enlarged and swol- 
len; they are exceedingly painful and intolerant 
of pressure ; and the same may be said of voluntary 
movements. Hence the patient remains in one 
position, avoiding motion as much as possible. 

Inasmuch as the masseters, as well as the laryngeal 
and pharyngeal muscles, are involved, the subject 
experiences much difficulty in masticating and swal- 
lowing food. But a still more serious complication 
is the invasion of the diaphragm and abdominal 
and intercostal muscles by the parasites, — a condi- 
tion which may cause such difficulty in respiration 
as to endanger the life of the patient. Undoubtedly, 
in some of the fatal cases of trichinosis, death is 
largely or entirely due to this interference with 
respiration. 

Finally, the characteristic pains of muscular rheu- 
matism are important, as they point to possible 
presence of redundant uric acid, thereby enabling 
us to effect in time the necessary modification in 
the dietetic regimen of the patient. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 107 

While the scope and purpose of this work will 
not admit of our pursuing the subject further, I 
think that enough has been said to illustrate in a 
striking manner the very great — I had almost said 
paramount — importance of pain as an element in 
general as well as neurological diagnosis. 



CHAPTER VII. 

THE CLINICAL AND MEDICO-LEGAL SIGNIFICANCE OF THE 
PHENOMENA EVOKED BY PAIN — OBJECTIVE METHOD OF 
DIAGNOSTICATING PAIN. 

Inasmuch as it often happens that individuals, 
either of their own volition or on account of an 
hysterical predisposition, erroneously declare that 
they feel pain, it becomes self-evident that every 
sign, however insignificant, which can aid the phy- 
sician in arriving at a true conclusion as to the 
sensations of the patient is of importance. 

This objective determination of the existence or 
non-existence of pain is, however, often beset with 
difficulty : first, because — as in certain obscure phases 
of visceral pain — a possible cause is not demon- 
strable; and, secondly, because the secondary effects 
of pain — cardiac, gastric, nutritive, and psychic — 
are not at all or but slightly developed. The evo- 
lution of these collateral effects is indeed dependent 
not only upon the intensity of the pain, but also 
upon its continuance ; so that it may very well hap- 
pen that, when the pain is of brief duration and of 
108 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 109 

relatively minor intensity, little, if any, change in 
the corporeal or psychic condition of the patient is 
discernible. In a large percentage of cases of severe 
chronic pain collateral phenomena of this sort are, 
however, present; and when their existence as a 
direct sequence of the painful onset is demonstrable, 
they possess a distinct diagnostic value. 

As the medico-legal significance of these things, 
though great, is often entirely overlooked, I shall 
take the liberty of enumerating the more striking 
facts. 

In the first place, there are often well-defined ap- 
pearances at the seat of pain. The most common 
are redness, heat, oedema, and tumefaction. Some- 
times, however, as in myalgia, there are no local 
changes whatever discernible ; and when the attack 
is acute, the testimony of the patient is about all 
we have to guide us. 

Among the common effects produced upon the 
organism at large by severe and long-continued pain 
are chronic, or at least persistent, nervous irri- 
tability, imperative conceptions of a disagreeable 
character, hypochondria, and melancholia, culmi- 
nating — as has often occurred in severe forms of tic 
douloureux — in self-destruction. Again, the subject 
may become the victim of obstinate insomnia, which 
in turn gives rise to moroseness, hallucinations, 

10 



110 PAIN. 

and perhaps ultimately to complete mental alien- 
ation. 

Although the facial expression of persons who 
are the victims of pain is not to be relied upon in 
a pathognomonic sense, it must nevertheless be ad- 
mitted that the physiognomy often affords valuable 
data of a corroborative character; moreover, in 
the case of the deaf and dumb or the aphasic, or, 
above all, when little children are concerned, it may 
constitute our only source of information as to the 
patient's true state of feeling. When, however, 
malingering is suspected, the data to be gained from 
a study of the face of the subject are of no value. 
That this is so will be readily understood when it is 
remembered that such persons are able to assume 
the states of feeling which lie at the root of the 
facial contortions ; so that, like actors, they are able 
to mentally " live in their role." 

The character of the facial mimicry peculiar to 
those who suffer pain is so familiar to all physicians 
as scarcely to merit detailed description. Indeed, I 
question very much whether a mere analysis of the 
muscular contractions involved would begin to con- 
vey the definite impression obtainable from a good 
photograph or, better still, from the contemplation 
of the individual himself. 

In addition to the psychical disturbances, grave 



PHYSIOLOGICAL., PATHOLOGICAL, CLINICAL. Ill 

modifications in the physical economy have often 
been observed. Chief among these are the cardiac 
derangements, described by a number of authors and 
experimentally investigated by Franck and Claude 
Bernard. 

Commenting on the discrepancies in the accounts 
given by different authors of these cardiac disturb- 
ances, Franck 1 observes that at all events the imme- 
diate effect is an arrest or slowing of the heart with 
the resultant changes in arterial pressure. He also 
confirms the previous observations of Magendie 
and Bernard, that excitation of the sensory roots or 
filaments of the spinal nerves gives rise to reflex 
stoppage of the heart with consecutive diminution 
in arterial pressure. 

Precisely similar facts have been ascertained clini- 
cally. Thus, Potain drew attention some ten years 
ago to the palpitations and syncope which were the 
direct sequence of certain neuralgias and injuries 
of the arms. 

Derangements of motility are a frequent concom- 
itant or sequence of pain. This is especially ex- 
emplified by the tonic and clonic spasms so char- 



1 Recherches experimentales sur les effets cardiaques, vasculaires 
et respiratoires des excitations douloureuses, Comptcs-Rendus des 
Seances de l'Academie des Sciences, vol. lxxxiii. p. 1109. 



112 PAIN. 

acteristic of the visceral neuralgias and so-called 
convulsive tic. The muscular contractions with 
which we are here confronted are clearly of reflex 
origin and require no special elucidation. The mus- 
cular relaxation sometimes encountered as an accom- 
paniment of pain is much less characteristic and 
consequently of subordinate diagnostic value. 

Disorders of nutrition, assuming the form of pro- 
gressive emaciation, and loss of muscular and mental 
vigor, are familiar to all physicians. 

Such vaso-motor anomalies as local hyperemia 
or anaemia, more especially the former, are common 
phenomena of various painful conditions; and the 
same may be said of the derangements of the special 
nerves, particularly those of sight and hearing. 

Arrest or appreciable diminution of the secretions, 
notably of the kidneys, is another well-known effect 
of pain. 

The irritability, insomnia, melancholy, and other 
nervous and psychical effects of pain have already 
been alluded to. Dyspepsia, loss of appetite, and 
appreciable diminution of the activity of the sali- 
vary glands are some of the most common compli- 
cations of various painful conditions. These gastric 
disorders are frequently accompanied by a consider- 
able elevation of temperature, which has been justly 
ascribed to the intensity of the pain alone. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 113 

Finally, pain, when of great severity, may result 
in immediate death, the fatal termination being evi- 
dently due either to nervous exhaustion or syncope. 

It would be a manifest omission were we to forget 
to mention what have been aptly termed subjective 
pains. Here we are confronted with painful sensa- 
tions which are referred by the patient to definite 
localities, the most careful inspection of which fails 
to reveal any morbid changes whatsoever. 

These so-called subjective pains, or "phantom 
pains" of the hysterical, are in reality nothing more 
than painful hallucinations, upon which, however, 
the subject, being ignorant of their genesis, is but 
too apt to construct erroneous ideas of various 
kinds. 1 

It must not be forgotten, therefore, that these 
phantom pains though of erratic development are 
none the less real to the subject herself. Hence 
undue harshness is to be avoided, and the same may 
be said of the old-fashioned expedient of taxing the 
patient with untruthfulness or other forms of moral 
turpitude. 

Concerning the Method to be Pursued in the 
Clinical Determination of the Existence or Non- 
Existence of True Pain. — From what has already 

1 Vide author's monograph on u Hysteria and Epilepsy." 
h 10* 



114 PAIN. 

been said, it is evident that the investigation of an 
essentially subjective phenomenon like pain is beset 
with no little difficulty. In the first place, it may 
be in consonance with the material interests of the 
patient to declare that he feels pain as the result of 
a real or imaginary injury. This has been witnessed 
again and again after railway or other accidents, 
when attempts have been made to collect large 
damages from corporations. 

Again, in the absence of all criminal intent, as in 
certain phases of hysteria, the subject declares that 
she suffers acutely; and yet we are quite unable to 
discover, even by the aid of the most careful exami- 
nation, any adequate cause for the alleged sensations. 
Here, as has previously been said, we have evidently 
to do with hallucinations pure and simple, the pain- 
ful conceptions being of central origin, and directly 
traceable to some general neuropathic condition. 
Finally, the subject may declare that he feels pain 
in a certain definite locality. "We examine the 
region in question, but find absolutely no lesion 
whatever; and yet the patient may be making 
his statements in perfect good faith, and he may 
even be in a condition of complete mental com- 
petency. In such a case as this, we should make 
every effort to determine, if possible, whether there 
be not some central irritation or organic lesion, 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 115 

which may be held responsible for the morbid sen- 
sations, erroneously referred by the subject to the 
periphery. The pains of ataxia and of some forms 
of neuritis are illustrations in point. 

And these preliminary observations bring us to 
the important question, How shall we conduct the 
clinical exploration in cases of suspected malingering, 
when pain is alleged to be the dominant or only 
symptom ? I shall only attempt to give a general 
reply, leaving the elaboration of the special points 
demanded by individual cases to the perspicacity and 
tact of the physician. In the first place, let there 
be a careful examination made of the periphery, 
and more especially of the alleged site of the pain- 
ful sensations. Now, experience has shown that 
much may be learned from careful palpation of 
the part, provided the patient be taken off his 
guard, so that the element of expectancy is ex- 
cluded. To this end, it is well to engage him in 
conversation on irrelevant matters, so that the 
examination may appear as of quite collateral im- 
portance. By such an examination we are able 
to determine whether there is increased sensitive- 
ness on pressure, whether there is inflammation, 
or whether there is tumefaction or other sign of 
gross lesion. As a further precaution against de- 
ception, the examination may be undertaken sev- 



116 PAIN. 

eral times, the agreement or discrepancies in the 
phenomena evoked serving as a basis of argument. 
The sensibility to temperature may also be tested 
in the same way. 

Finally, we may administer in the food of the 
patient, or otherwise without his knowledge, an 
hypnotic of sufficient potency to remove the pain 
complained of. If in the face of this, after a suffi- 
ciently long interval to insure absorption of the 
medicament, he still declares that the pain per- 
sists as before or has increased in vehemence, we 
may conclude, in the absence of hysteria or other 
psychical defect, that wilful deception is in all 
probability being practised. 

Let me also add that the failure of the collateral 
symptoms described by the subject to agree at all 
with any known type of disease is of itself calcu- 
lated to arouse suspicion. 

When all has been said, however, that can reason- 
ably be said on the objective recognition of pain, it 
must be confessed that in some cases even the most 
expert diagnostician may find himself embarrassed. 



CHAPTER VIII. 

THE MEDICO-LEGAL RELATIONS OF PAIN, CONTINUED— SPINAL 
CONCUSSION. 

In the majority of cases of surgical injury accom- 
panied by pain the determination of the amount of 
damages consistent with equity is a comparatively 
easy matter, the degree of interference with the sub- 
ject's occupation occasioned by the accident itself 
serving as a basis of computation, quite irrespective 
of pain or other collateral effect engendered. 

When, however, the extraneous appearances of 
injury are little or not at all in evidence, the 
alleged phenomena being purely subjective, the 
difficulty of determining the genuineness of the 
latter is enormously enhanced. These observations 
are especially applicable to the curious affection of 
the nervous system which is the sequence of railway 
or other accidents, and to which the name " spinal 
concussion" has been given. Let me say, however, 
at once that, in my opinion, " cerebro-spinal con- 
cussion" would be a designation more in accord- 
ance with the symptoms, since not a few of these 

117 



118 PAIN. 

are clearly due to derangement of the intracranial 
structures. 

Since this spinal, or cerebro-spinal, concussion 
has probably given rise to more litigation than any 
other painful affection, it is eminently important 
that every physician should at least be thoroughly 
acquainted with its more important features. I 
have therefore decided to devote a short chapter 
to its consideration, which, should the reader be 
already acquainted with the subject, may be passed 
over. 

Symptoms. — If a man be suddenly precipitated 
from an elevation, so that he strikes with violence 
upon his back, or if he be caught between two 
seats of a railway car in the course of an accident, 
so as to bruise, say, the lumbar portion of the spine, 
a train of grave symptoms may be developed 
pointing to more or less profound derangement of 
the functions of the cord. There may be imme- 
diate paraplegia or some other phase of paralysis ; 
there may be retention of urine; there may be 
various forms of paresthesia?, — formication, numb- 
ness, or even total anaesthesia of the affected parts ; 
or, finally, there may be paralysis accompanied by 
one or more of these phenomena. Sometimes, too, 
after a certain amount of febrile disturbance of 
brief duration, the symptoms begin to abate, and 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 119 

eventual complete recovery takes place. Again, the 
termination may not be so favorable. We may have 
to do with more or less persistent dorsal pain, with 
numbness or sensations of pins and needles, accom- 
panied by depression, derangements of memory, and 
other symptoms pointing to profound implication 
of the cerebro-spinal system. The spinal tender- 
ness present in such cases is often of an exquisite 
and obstinate character. If, in addition to direct 
concussion of the spine, a blow upon the head has 
also been received, it not infrequently happens that, 
in the course of time, epileptiform seizures are 
added to the cord symptoms. The clinical history 
is, of course, somewhat changed by such a compli- 
cation, and the same may be said of the prognosis, 
which is much clouded. Finally, the blow upon 
the spine may be but slight or altogether absent, 
the subject being merely thrown violently about, as 
in certain railway accidents. Under these circum- 
stances the symptoms are often slowly evolved, and, 
though frequently less severe than when the se- 
quence of a direct and violent traumatism, they 
nevertheless partake of an insidious and lethargic 
character, which puts the patience of both client 
and physician to a severe test. 

Accidents of this class have now become common, 
in consequence of the manifold complications of 



120 PAIN. 

modern society, and especially of those which relate 
to transportation. 

As already noted, the painful localities along the 
spine, which are such constant features of these 
cases, are eminently worthy of the attention of the 
physician, since they bear a significant relation not 
only to a scientific diagnosis, but to effective thera- 
peutics as well. 

At this portion of the discussion I believe that I 
cannot do better than cite a case or two from my 
own case-book by way of illustration. 

H. C, merchant, aged fifty-two years, of strong 
muscular constitution, consulted me in February, 
1884, for a train of severe nervous symptoms, which 
caused great anxiety both to himself and family. 

The following are the more prominent points in 
the history of the case : 

One year previous to consulting me he had the 
misfortune to travel on a railway train which met 
with a serious accident. The casualty in question, 
as it afterwards appeared, was caused by the spread- 
ing of the rails immediately in front of a long 
trestle-work. Several of the coaches were thrown 
from the trestle into the water, many of the occu- 
pants being caught between the seats or thrown 
about and severely injured. Others, again, were 
confined beneath the flying debris and drowned; 



121 

while yet others succeeded in making their escape 
from the windows of the coach. Among the latter 
was a distinguished officer of the United States 
army and the gentleman with whose history we are 
now concerned. Had the coach, after striking the 
bottom, not rolled over upon its side, it is probable 
that those within, who had not been killed outright, 
would have perished by drowning. As it happened, 
however, a large proportion of those within the 
submerged cars escaped with their lives. It cannot 
be said, however, that these persons were all un- 
scathed, for, though the wounds received were in 
most cases not serious, the after-effects caused by 
the violent shaking were of a severe character. 
Among those who developed severe symptoms a 
considerable time after the accident was the gentle- 
man who forms the subject of this brief history. 
On emerging from the water, he became conscious 
that the right shoulder and the lower portion of the 
back were somewhat stiff and sore. At the same 
time he felt a dull pain throughout the whole 
dorsal region. These pains and the accompanying 
soreness in the shoulder soon disappeared, however, 
and the patient was beginning to regard himself as 
perfectly well, when, several weeks after the acci- 
dent, he complained of numbness in the third, 
fourth, and fifth fingers, particularly pronounced in 
F 11 



122 PAIN. 

the right hand. This numbness was accompanied 
by tremor of both hands, evoked by every attempt 
to execute voluntary movements. At the same 
time, he experienced " dull, tired" feelings after 
walking even short distances, accompanied by great 
mental depression. As a coexistent factor of the 
above symptoms, the patient remarked a progres- 
sive decline in his sexual powers, so that, at the 
time of visiting me, his abilities in this direction 
were nil. The testicles seemed unusually small, 
the scrotum was tightly contracted about them, and 
the penis was retracted, so as to expose only about 
half an inch. Altogether, the sexual apparatus was 
in size and general appearance analogous to that 
of an infant. On examining the spine, no great 
tenderness could be discovered ; but on passing the 
wire brush along the spinous processes, from the 
cervical region to the sacrum, an exceedingly tender 
point was discovered in the neighborhood of the 
eleventh dorsal vertebra. The course of this case 
was a long and tedious one. 

Sleep being profoundly deranged, the patient was 
placed on twenty-grain doses of the bromides, to be 
taken three or four times a day. Small doses of 
chloral were also given at night, during the first 
few weeks of treatment, combined with the tincture 
of hyoscyamus. Strychnine was not well borne, and, 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 123 

according to the patient's statement, exaggerated 
the lumbar pains. In order to relieve the latter, 
blisters were applied throughout the painful region, 
but without greatly diminishing the spinal soreness. 
Prolonged applications of galvanism were more ef- 
fectual in abating the irritation; and accordingly 
the constant current was applied every other day 
for two months, at the end of which time marked 
benefit had been obtained. The tingling and numb- 
ness of the limbs remained for some time longer ; 
but after the lapse of four or five months it, too, 
had entirely vanished. Walking had also begun 
to afford pleasure, and could be indulged in without 
the fear of subsequent lassitude. 

The most difficult complication to combat in this 
case was the complete loss of sexual power, ac- 
companied by the retraction of the organ. This 
retraction of the penis was certainly phenomenal, 
as already observed. In order to remedy the condi- 
tion dry cupping of the penis was resorted to, and 
continued daily for over three months, and every 
other day for the subsequent four months. By the 
aid of this treatment, combined with douches, the 
passage of the cold sound, such remedies as the 
chloride of gold, iron, and the cocoa preparations, 
I finally succeeded in completely restoring the 
patient's sexual powers, so much so, in fact, that 



124 PAIN. 

in due time a further addition was made to his 
family. 

This case affords an excellent illustration of the 
slow insidious onset of the affection, of the evo- 
lution of severe and obstinate symptoms without 
local traumatism of commensurate importance, and, 
finally, of the ultimate success attending the treat- 
ment of what at the outset had all the features of a 
practically hopeless case. This patient remained 
under my immediate care nineteen months. At 
the end of that time, with the exception of occa- 
sional attacks of depression, the cure was complete. 
Since discontinuing treatment I have seen the pa- 
tient from time to time, and some months ago he 
informed me that these attacks of depression had 
entirely left him, and that, in short, he is " as well 
as he has ever been in his life." 

The following case, also taken from my case-book, 
is a good illustration of some of the milder phe- 
nomena sometimes evoked by concussion. As in 
the cases already cited, marked localized tenderness 
of the spine was present; but the condition was 
treated in a more direct and effective manner. 

J. M., a married man of forty-five years of age, 
of nervous temperament and slight physique, con- 
sulted me four years ago on account of a train of 
nervous symptoms which caused him both anxiety 



PHYSIOLOGICAL, PATHOLOGICAL," CLLN1CAL. 125 

and annoyance. The salient points in his case were 
these : 

About eighteen months before consulting me he 
had met with an accident on the Long Branch Rail- 
way. He was violently thrown about the car ; his 
head was cut, and he received a severe bruise in the 
left lumbar region. On extricating himself from 
the wreckage, he noticed that his legs felt " sleepy" 
and that there was a tingling sensation in the right 
side of the face. These sensations disappeared en- 
tirely within the following week, so that he was able 
to resume the obligations of an active business life. 
All went well for a time, the duties of society and 
business receiving a punctilious attention, which 
had never been exceeded, even when the patient 
enjoyed the most perfect health. Some five months 
subsequent to the accident, however, he began to 
complain of great lassitude, particularly during the 
early morning hours. At the same time sleep be- 
came profoundly deranged, and even when he was 
certain that he had slept for a few hours, he com- 
plained that his sleep " did him no good." For- 
merly of a cheerful disposition, he now became the 
victim of protracted periods of depression ; and his 
memory, previously of average strength, had be- 
come so fickle that he was obliged to carry a note- 
book in which to record his most trivial routine 

11* 



126 PAIN. 

engagements. He also suffered from soreness of 
the back and occasional attacks of facial neuralgia. 

On examination, his muscular system was found 
to be weak and flabby, his heart's action feeble and 
irregular, and his general condition one of pro- 
nounced anaemia. Pressure along the spinal column 
revealed two points of marked soreness, the one in 
the dorsal region, the other at the level of the 
second lumbar vertebra. From the first of these 
tender spots radiated — especially on sudden changes 
in temperature — intercostal pains of considerable 
intensity. 

Having placed the patient on a tonic regimen 
and prescribed the iodide and bromide of potash, 
the latter to be taken in cumulative doses during 
the afternoon and evening, I directed my attention 
to the points of tenderness in the spine. Instead 
of treating these by the long and tedious method 
of local galvanization, I decided to try the efficacy 
of local injections of cocaine and pyrogallic acid in 
solutions of low percentage. I will merely add 
that I succeeded in affording much relief to the 
patient; so that, after the injection had been re- 
peated a few times, the soreness disappeared en- 
tirely. 

When I compare the promptness of the relief 
obtained in this case with the long course of pallia- 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 127 

tive treatment required in the case detailed at the 
beginning of this chapter, I am the more surprised 
that greater efforts have not heretofore been made 
to influence the functions of the cord by resort to 
more direct methods. 

Having thus detailed some of the complications 
often encountered in even the milder phases of 
concussion of the spine, it now becomes necessary 
to leave this interesting field, for it is self-evident 
that to pursue the matter further would be to tran- 
scend the natural limits of a work of this general 
character. 



CHAPTER IX. 

OF THE INSOMNIA AND MELANCHOLIA OP PAIN. 

We have already referred in previous chapters 
to the nutritive and cardiac disturbances, both of 
which are so frequently evoked by severe pain, es- 
pecially when long continued. But there are other 
sequences of pain which are, if anything, even 
more important than these; and this may be said 
especially of the sleeplessness and melancholy so 
often met with in the course of painful affections. 
I repeat that these two complications are invested 
with unusual significance from a prognostic point 
of view ; for it not infrequently happens that singly, 
but more often together, they are the forerunners 
of suicide or insanity. In view, then, of the gravity 
of their significance in this respect, it will not be 
time misspent if we devote a short chapter to the 
consideration of insomnia and melancholia, more 
especially as they occur as the direct result of pain. 

For the sake of convenience, from both a physio- 
logical and a clinical point of view, insomnia may be 
divided into an idiopathic and a symptomatic variety. 
128 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 129 

In idiopathic insomnia the etiological conditions, 
though not always discoverable, reside apparently 
in the brain itself, since factors extraneous to that 
organ, which might account for the occurrence of 
the sleeplessness, are entirely wanting. 

Symptomatic insomnia, on the contrary, is trace- 
able to sources of irritation outside the cranial cav- 
ity. This is the variety of sleeplessness which we 
encounter in the course of painful affections, espe- 
cially those of long duration. 

It will be well to examine the phenomena of 
these two varieties of insomnia somewhat more 
in detail. 

As has been previously noted in connection with 
the discussion of the phenomena of pain, it often 
happens that the painful paroxysms exhibit re- 
markable regularity in their occurrence, the most 
frequent manifestation of this periodicity being 
the appearance of the seizure at a certain time in 
the evening. Under these circumstances, the pa- 
tient passes the greater portion of the day in a 
condition of lassitude, but also of comparative ex- 
emption from suffering. 

The skin has usually a dull sallow appearance, 
and the eyes are sunken and devoid of their normal 
lustre. 

The urine is often scant and highly colored, 



130 PAIN. 

and a constipated habit is the usual but not in- 
variable rule. Exceptionally, there may be ob- 
stinate diarrhoea, which contributes not a little 
to the general enfeeblement of the subject. In 
the idiopathic variety of insomnia, the lassitude 
during the interval of wakefulness is quite char- 
acteristic, amounting, as it often does, to the most 
pronounced lethargy. Uncontrollable yawning is 
present in almost every case. When expostulated 
with on account of his listlessness, the subject be- 
comes morose and sullen, regarding the well-meant 
advice as an impertinent interference. The small 
ills of life assume commanding proportions, and 
by a system of loose, pessimistic reasoning he is 
led to regard them as the forerunners of an im- 
pending catastrophe. 

On betaking himself to bed, sleep fails to put a 
quietus to the gloomy train of thought; he tosses 
from side to side; he removes the bedclothes; he 
replaces them again; he changes his position a 
hundred times, all in a vain attempt to win uncon- 
sciousness. When at last, after a prolonged vigil, 
sleep supervenes, — partaking, as it inevitably does, 
of the perverted cerebration of the previous hours 
of wakefulness, — it utterly fails to refresh the sub- 
ject either physically or mentally. Indeed, from 
an extensive practical experience with the various 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 131 

derangements of sleep, I am convinced that per- 
verted dreams and unconscious cerebration are more 
frequently encountered in the sleepless than among 
any other class of sufferers. In view of the im- 
perfect nature of this sleep, it is not surprising that 
daylight finds the subject completely prostrated, 
and quite unable to resume his accustomed activities 
with even moderate energy. 

Tea, coffee, brandy, and even morphine are now 
invoked with the hope of obtaining a renewal of 
vigor. But the relief thus obtained is necessarily 
transitory, since there is no known stimulant capa- 
ble of replacing the regenerative processes in the 
cerebral ganglia which are carried on during nor- 
mal sleep. 

The temperament of the individual has, as may 
readily be conceived, an appreciable influence in 
determining the character of the attack. When he 
is predominantly emotional, the insomnia is of a 
far graver kind than would be the case were the 
mind of an essentially intellectual cast. Worry, 
adversity, and suspense are, indeed, things which 
are especially disastrous to emotional persons, whose 
powers of adaptation in the face of such exigencies 
are limited. 

Precisely the opposite is true of those in whom 
the ratiocinative faculties predominate; for, when 



132 PAIN. 

they are assailed by an acute attack of insomnia, 
we find such, persons much less irritable and de- 
pressed, simply because the emotional element in 
the psychical organization is either inhibited by the 
reasoning faculties or is practically wanting. 

Finally, as may be readily deduced from the fore- 
going remarks, a vivid imagination is certain to add 
to the severity of an attack of insomnia ; since the 
fancy, instead of becoming progressively subdued, 
increases in activity, with the result that myriads 
of fantastic, semi-incoherent ideas arise spontane- 
ously, disappearing again, but only to return with 
new combinations added to their grotesque array. 

Such is a true picture of idiopathic insomnia; 
and I may add, also, that many of its attributes are 
likewise common to the symptomatic type of sleep- 
lessness, which it will now be well to consider briefly. 

Symptomatic insomnia, as its name implies, is that 
form of sleeplessness which accompanies chronic af- 
fections, especially those in which pain more or less 
severe or long continued is a prominent feature. 

As most persons are aware from personal experi- 
ence, sensory impressions should be eliminated as 
far as possible in order to insure the occurrence of 
the most perfect type of sleep. Hence, when there 
is present neither irritation within ilor at the sur- 
face of the body, and when, moreover, there is an 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 133 

absence of impressions through the special senses. 
it is evident that the physiological requirements of 
the proposition are fulfilled. 

During normal sleep, it is true, the perceptive 
mechanism is obtunded, because of the exhaustion 
due to the previous stage of activity, and, as a con- 
sequence, slight sensory impressions which during 
wakefulness would have led to active perception 
leave no imprint upon the sluggish protoplasm. 
When, however, impressions of considerable inten- 
sity are transmitted to the exhausted receptive cen- 
tres, the latter become irritated and aroused from 
the lethargy consequent upon exhaustion, and finally 
the entire cerebral mechanism is aroused : the indi- 
vidual is awakened. Herein lies the explanation of 
the sleeplessness engendered by pain, which, as in- 
dicated in an earlier chapter, is nothing more nor 
less than exaggerated common or special sensation. 
But even in cases where the pain is slight, but of 
relatively long duration, wakefulness of a distressing 
character, coupled with irritation of the central ner- 
vous system out of all proportion to the exciting 
cause, may be engendered. An excellent illustra- 
tion of this fact is afforded by the insomnia due to 
the application of blisters, concerning which Dr. 
Robert J. Graves wrote in the following suggestive 
way over forty years ago : " The bad effects on the 

12 



134 PAIN. 

nervous system occasionally produced by the appli- 
cation of blisters are somewhat analogous to those 
which result from wounds and other external inju- 
ries, and to be accounted for on the same prin- 
ciple. . . . The delirium and sleeplessness arising 
from blisters constitute a by no means uncommon 
disease." 

It is quite evident, then, that irritative processes 
involving the terminal organs of the centripetal 
nerves represent the pathological factor of chief 
importance in the genesis of secondary insomnia. 
Hence it follows that those acute and chronic dis- 
eases which are accompanied by severe or prolonged 
pain are the most prolific sources of this variety of 
sleeplessness. 

The Melancholy of Pain. — When a person has 
suffered acutely for a short time, or, as more fre- 
quently happens, when the pain has been of less 
severity but of longer duration, a condition of 
mental atony may be engendered, ranging from 
more or less irresponsiveness to ordinary impres- 
sions to melancholia, — simple, delusional, or sui- 
cidal. 

With these conditions of depression occurring in 
the course of, or as the sequence of, painful affec- 
tions the physician is often enough confronted. 
The subject, therefore, is clearly invested with prac- 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 135 

tical interest ; and for this reason I believe that no 
apology will be required for the insertion of the 
following brief remarks. 

Simple and Hypochondriacal Melancholia. — This 
is by far the most common form of depression en- 
countered in the course or as the sequence of vehe- 
ment or prolonged pain. Its most striking char- 
acteristic is a predominance of purely emotional 
disturbances, the intellectual or volitional aberra- 
tions being little or not at all in evidence. In the 
beginning the patient suffers from loss of appetite 
and constipation, followed, in a short time, by more 
or less disturbance of sleep and listlessness during 
the day. Though formerly, it may be, of an ener- 
getic, sanguine disposition with definite predilec- 
tions, both as regards work and amusements, he 
now manifests a positive dislike for all pursuits; 
and this aversion may culminate in change in pro- 
pensities and ideals. This inversion of the instincts 
may be exhibited in dislike for the familiar associa- 
tions of the family, by irascibility, by loss of cour- 
age, and by distaste for society. Loss or at least 
marked decrease of sexual vigor is a striking feat- 
ure at this time, and the same may be said of the 
diminution in weight and augmented sensitiveness 
to cold, which latter feature leads the subject to dis- 
like bathing in water of low temperature, subse- 



136 pain. 

quent reaction being but slightly marked, or even 
entirely absent. 

Like the neurasthenic, the subject of melancholia 
is usually worse in the morning than at night, when, 
for some unaccountable reason, there is a partial 
though temporary revival of vigor. The lustreless 
appearance of the eyes, the coated tongue, the 
dry, inactive appearance of the skin, the mental 
inertia, the emotional irresponsiveness, may all be 
observed during these early hours, and they consti- 
tute a complex of symptoms so characteristic as to 
be practically unmistakable. 

Not only is the initial period of simple melan- 
cholia to be looked upon as of essentially sane 
character, but, in a large percentage of cases, the 
entire course of the disease must likewise be so 
regarded. This at least is true in the light of cur- 
rently-accepted definition. The same may likewise 
be said of certain mild phases of hypochondriacal 
melancholia, where the erroneous ideas are shifting 
in character and devoid of the inherently impossible 
character exemplified by the more serious varieties 
of the affection. "Where this grave delusional type 
of the disease prevails, the subject may proclaim 
that he has three stomachs or none at all, that " his 
liver fills the entire abdominal and thoracic cavi- 
ties," that " he has seven kidneys," and the like. 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 137 

The shifting, less preposterous types of hypochon- 
driacal delusion are those most commonly evolved 
in the course of painful affections. They consist for 
the most part in abortive attempts to explain the 
origin of the painful sensations; and, though un- 
scientific enough in themselves, are nevertheless 
well within the limits of mental sanity, for they are 
no worse than might reasonably be anticipated from 
persons ignorant, or largely ignorant, of medical 
matters. Thus, we find ataxics strenuously insisting 
that their pains are due to " rheumatism," and suf- 
ferers from lumbago declaring that their "kidneys 
are affected," in the face of the most conclusive 
proof to the contrary. As we have said, these 
things are common enough as the sequence of pain, 
especially of a prolonged, unyielding type; but since 
they are rarely the precursors of serious conse- 
quences, nothing more than a humorous considera- 
tion is usually accorded them. 

Suicidal Melancholia. — Self-destruction represents 
the culminating catastrophe, the most drastic expres- 
sion of mental depression. That this is indeed the 
truth will be readily conceded when it is remem- 
bered that the love of life, the instinct of self-preser- 
vation, is the strongest impulse in man, as well as 
the lower animals. When this fundamental instinct 
is obliterated, or even reversed, so that the patient 

12* 



138 PAIN. 

is not only indifferent to life, but actually craves 
death, the change in the affective and instinctive 
faculties is certainly the most profound imaginable. 

The motive which impels the subject to desire 
or attempt self-destruction is, however, not always 
the same. Sometimes it assumes the form of a 
desperate attempt to avoid imaginary evils; or it 
is the outgrowth of an imperative and often sudden 
impulse; or, as sometimes undoubtedly happens, 
it is the result of a deliberate process of reasoning. 
• The last-mentioned motive is that most frequently 
encountered in severe intractable pain, as we find 
it, for example, in tic douloureux. In despair at the 
fruitless efforts to obtain relief, and worn out by 
ceaseless vigils, the horrors of which are too great 
to be expressed in words, the unfortunate grasps 
deliberately at death as the sole means of obtaining 
release. 

The essentially sane character of the ratiocination 
which has led to the unnatural and tragic ending is 
revealed by the epistles written by such persons im- 
mediately before the commission of the fatal deed. 

Delusional Melancholia. — By this designation 
is to be understood that form of melancholy in 
which one or several delusions are the most strik- 
ing feature from the beginning. Indeed, it is this 
early appearance and prominence of the erroneous 



PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 139 

ideas which leads those unfamiliar with mental 
pathology to regard the general morbid condition 
as the sequence of the delusions. This, however, 
is crude reasoning, as the persistent disturbance of 
cerebral nutrition is the principal thing. 

As this form of melancholia is, however, much 
more rarely met with in painful conditions than 
the varieties of depression previously described, it 
will not be advisable to pursue the subject further. 

In the following chapter the means at our dis- 
posal for dealing most effectively with those two 
distressing complications of pain, insomnia and 
melancholia, will be considered with much fulness. 



PART II. 

THE SPECIAL THERAPEUTICS OF PAIN. 



CHAPTER X. 

CONCERNING THE IMPORTANCE OF REST IN THE TREATMENT 
OF THE NERVOUS SYMPTOMS ENGENDERED BY PROLONGED 
AND SEVERE PAIN. 

In the previous chapter the insomnia and melan- 
choly which constitute such important sequences of 
severe and protracted pain have been considered at 
some length. What has there been said has served, 
I trust, to exhibit the exceeding importance of the 
subject, so that further insistence on that point is 
unnecessary. Nothing, however, has yet been said 
of the best manner of dealing with those compli- 
cations; this we shall now attempt to do as suc- 
cinctly as possible. 

Let me say, then, at once, that in my judgment 
the most effective means of neutralizing the ill 
effects of both the melancholy and the sleeplessness 

140 



THE SPECIAL THERAPEUTICS OF PAIN. 141 

engendered by protracted pain is found in the series 
of expedients commonly grouped together under 
the general designation of " Rest/' or the " Rest 
Treatment." 

But, as there has been much crudeness in the 
conceptions entertained by many as to the signifi- 
cance of these terms, I shall take the liberty of dis- 
cussing the whole question of rest with some elabo- 
rateness, trusting that by so doing I shall be able to 
remove some of the nebulousness which has sur- 
rounded the whole subject, alike in its physiological 
and clinical relations. 

Of Rest in General. — When we associate the idea 
of rest with a mechanism, we involuntarily think 
of cessation of motion. "When, however, we speak 
of rest in connection with living organisms, — when 
we employ the term in its true physiological sense, 
— not only does the element of functional quiescence 
enter into the conception, but that of repair as well. 
The demonstration of the truth of this idea has 
been one of the many services of modern physi- 
ology. Still, it must be admitted that mankind has 
always entertained more or less true, though crude, 
ideas of the nature of rest as exhibited by living 
beings. 

The laborer, after the noonday remission, is con- 
scious of reinvigoration, is aware of certain changes 



142 PAIN. 

in his stiffened and unwilling muscles which render 
the latter supple and serviceable once more. The 
student or weary professional man, after a night's 
sleep, becomes aware of certain changes in his 
mental mechanism which enable him to resume 
intellectual labor with positive enjoyment. 

It is clear, therefore, that such familiar facts as 
these must at an early date have led men of intelli- 
gence to associate the idea of repair with that of 
rest. The conception was, however, more or less 
vague; and not until modern experimental physi- 
ology had shown the inseparable relation between 
function and tissue metamorphosis did crude sur- 
mises give place to definite scientific proof. 

One of the greatest practical benefits accruing 
from the knowledge of the physiological significance 
of rest has been the adaptation of such rest to the 
treatment of disease. Now, the fulfilment of the 
requisites of physiological rest, when applied to 
the organism as a whole, is a simple matter. In 
short, we have merely to pay heed that there be 
neither an excess of mental nor physical work ; and 
then, translating the word "repair" into "nutri- 
tion," it only remains to see to it that the indi- 
vidual is provided with food of a kind suitable to 
the reparative exigencies of the organism at large. 
When, however, it becomes expedient to afford 



THE SPECIAL THERAPEUTICS OF PAIN. 143 

rest to a single organ, for example, the solution of 
the problem is by no means so simple ; for we have 
then to "rest" a particular physiological system 
over and above the remainder of the economy, and, 
at the same time, to make provision for the specific 
nutritive demands of the organ which we desire to 
benefit. It follows, therefore, that, clinically speak- 
ing, there is not one system of rest, but, on the 
contrary, there must be several. In the following 
paragraphs I shall consider three kinds of rest : (1) 
muscular rest ; (2) spinal or medullary rest ; and (3) 
cerebral rest. 

Muscular Rest. — This is the simplest of the three 
forms of rest which we are about to consider, and 
its realization makes demands upon none but the 
most ordinary resources of therapeutics. The day- 
laborer who has passed many hours in toil experi- 
ences a certain amount of fatigue in the muscles, — 
a local weariness which is relieved in a short time 
by keeping the muscles in a state of simple quies- 
cence. This is not, however, the form of muscular 
rest which the physician has occasion to employ in 
practice ; for instead of healthy, robust muscles, he 
has usually to do with a flabby, ill-developed mus- 
cular apparatus requiring attention of a special 
kind. In dealing with this latter class of cases, it 
is first necessary to cause a sufficient flow of blood 



144 PAIN. 

through the ill-developed muscle to facilitate repair 
of the stunted organ ; and, secondly, it is advisable 
to place the latter in a state of complete repose for 
a considerable length of time after the blood-current 
has been diverted, so that the processes of repair 
may be realized to their fullest extent. The deri- 
vation of the blood-current for the benefit of the 
muscle may be accomplished in a variety of ways : 

1. The patient may be urged to employ his mus- 
cles in vigorous exercise for a certain length of 
time, and to follow such exercise by more or less 
complete repose of the motor apparatus. This is 
the system pursued in gymnasia and in the training 
preceding athletic contests; to its beneficial influ- 
ence is to be ascribed the enormous muscular devel- 
opment often attained by men of sedentary pursuits. 

2. By resort to profound and vigorous massage 
it is possible to cause a copious flow of blood to 
the muscles. This method of derivation is the 
most generally applicable, and will be found use- 
ful in the treatment of a large class of feeble in- 
dividuals. 

3. Finally, the blood-current may be caused to 
flow through the muscle in copious measure by 
means of Junod's apparatus, — a method of treat- 
ment which has, however, a more or less re- 
stricted application, being perhaps best adapted 



THE SPECIAL THERAPEUTICS OF PAIN. 145 

to the management of peripheral paralysis asso- 
ciated with muscular atrophy. 

There is one other factor of importance in con- 
nection with muscular rest, — viz., the introduction 
of proper nourishment into the system. Where 
the stomach is in good condition there is no great 
difficulty in solving this portion of the problem. 
The patient is to be put upon a diet consisting 
largely of meat, eggs, and milk, a menu which 
may be varied from time to time to suit the varying 
wants and idiosyncrasies of the patient. Should 
the stomach prove recreant, or should that organ 
have been the seat of severe and long-standing 
dyspepsia, resort may be had to rectal alimentation. 
In addition, we may employ subcutaneous injections 
of cod-liver oil with a view to further improvement 
of the processes of nutrition. 

Spinal Rest. — A moment's reflection upon the 
offices of the spinal cord will serve to show that 
any system designed to afford physiological rest 
to that organ must fulfil a twofold end, — viz. : 

1. The elimination of those motor and sensory 
impulses which under ordinary circumstances are 
transmitted through the conducting paths of the 
cord; and, 

2. The curtailment, as far as possible, of reflex 
action. 

Q k 13 



146 PAIN. 

The requisites of physiological cord-rest are very- 
well realized in the system adopted by Dr. S. Weir 
Mitchell. The essential features of this system are 
the combined use of rest, massage, electricity, and 
over-feeding. 

As regards the utility of Dr. Mitchell's method in 
the treatment of functional affections of the spinal 
cord, there can, I believe, be but one opinion. It is 
impossible, indeed, to say too much in praise of it 
when thus employed. As to its applicability in the 
treatment of those affections which are unquestion- 
ably cerebral in origin and directly traceable to ex- 
haustion, irritation, and other forms of malnutrition 
of the brain itself, that is a matter which I believe 
is open to serious question. But of this I shall have 
something to say at a future stage of the argu- 
ment. 

Cerebral Rest. — It is clear from the foregoing 
remarks that, as applied to the brain, rest means 
something totally different from that which is under- 
stood by the term when used in connection with the 
muscle, the joint, or the spinal cord. This radical 
difference is chiefly owing to the fact that, the brain 
being the organ of the intellectual processes, rest, in 
so far as it concerns that mechanism, means nothing 
less than a cessation of mentalization, with all thereby 
implied. It is impossible by a mere fiat of the will 






THE SPECIAL THEKAPEUTICS OF PAIN. 147 

to cause cessation of thought; the very idea itself 
embodies a contradiction ; for will itself, as physio- 
logically understood, is not to be looked upon as 
something sui generis, as an abstract impalpable unit, 
but rather as the outgrowth of a series of exceed- 
ingly complex psychical processes. From this propo- 
sition it follows, therefore, that the exercise of will 
is quite as much a consumer of cerebral energy as 
the mental processes which are necessary, for ex- 
ample, to the solution of a problem in Euclid. The 
same may be said of consciousness and the impres- 
sions which underlie it. To sum up the argument, 
the whole drift of modern psychical and physio- 
logical research goes to show that all phenomena 
known as mental are contingent upon a consump- 
tion of cerebral energy. It now becomes pertinent 
to inquire : 

1. Does nature provide an intermission in these 
mental processes ? and, 

2. If so, can such cessations in cerebral activity 
be induced or prolonged, and finally utilized, in the 
treatment of functional brain affections ? 

To the first question the reply is sufficiently ob- 
vious : nature does unquestionably afford more or 
less complete repose to that portion of the cerebral 
mechanism engaged in the evolution of mental 
phenomena; such repose being undoubtedly the 



148 PAIN. 

chief office of sleep. True, it is questionable 
whether absolute quiescence of the mental faculties 
is always attainable, even during sleep; the ideal 
rest afforded by the latter being frequently marred 
by the occurrence of dreams and more or less un- 
conscious cerebration. Still, the fact remains that 
during sleep cerebration is at a minimum. Then 
again, unconscious cerebration and dreaming are 
after all to be regarded rather as exceptional feat- 
ures than as physiological phenomena of sleep. 

To the second question, Oan a cessation in cere- 
bral activity be induced and prolonged? I reply, 
most certainly, and that too without inordinate 
drugging, which is considered so indispensable by 
those little accustomed to deal with insomnia, ex- 
haustion, and other anomalies of nutrition affecting 
the cerebral centres. Before entering upon a de- 
scription of the scheme of treatment by which I 
have sought to practically realize the benefits of 
cerebral rest, I desire to cast a retrospective glance 
at my early publications on the subject, as certain 
of them seem to have given rise to some misunder- 
standing. 

In 1882 I published a brief article 1 in which were 
detailed sundry experiments undertaken by myself 

1 Medical Kecord, February 18, 1882. 



THE SPECIAL THERAPEUTICS OF PAIN. 149 

with a view to elucidating certain problems con- 
nected with cerebral physiology. 

On a subsequent occasion 1 I added, "If it be ad- 
mitted that the ganglia are directly or ultimately 
dependent for their functional activity on the good 
offices of the blood-stream, it becomes perfectly 
evident that limitation of blood-supply means cur- 
tailment of ganglionic function." By this state- 
ment I did not wish to imply that cerebral rest, in 
a clinical sense, was to be obtained by simply caus- 
ing anaemia of the brain; my sole desire was to 
draw attention to the well-established fact that the 
oxidative processes within the cerebral ganglia are 
diminished during the repose of the latter, and that 
the anaemia of sleep, though occurring as a conse- 
quence of the exhausted condition of the ganglia, 
was not, therefore, to be regarded as of no impor- 
tance in the chain of physiological events. A few 
months after the publication of this little memoir 
I took occasion to give further expression to my 
views relative to the physiology of sleep. On that 
occasion I said that the two most important factors 
of sleep are ganglionic exhaustion and a physiologi- 
cal degree of anaemia. 



Carotid Compression, Anson D. F. Kandolph & Co., New 
York, 1882. 

13* 



150 PAIN. 

The experimental data which I cited in corrobo- 
ration of these views were not derived from the 
observations of others, but were mainly the out- 
growth of personal investigation and experience in 
the clinic. I felt, therefore, that, if treading upon 
ground of acknowledged difficulty, I was at all 
events not trusting to the fickleness of mere deduc- 
tive reasoning. The logic of subsequent events has 
in no wise shaken my confidence in the opinion 
then expressed, so that, at the present, I see no 
reason for changing the tenets upon which the 
system of cerebral rest — presently to be described — 
is essentially based. 

The practical problem of cerebral rest I have 
therefore sought to systematize as far as possible, 
but in communications on the subject I have not 
omitted to exhibit the many-sided aspect of the 
question. Thus, in a paper 1 published in 1883, I 
took occasion to show the paramount importance 
of systematized, physiological rest in the treatment 
of aggravated cases of cerebral exhaustion. I 
showed, moreover, that the essential feature of such 
a system was prolonged sleep. In a paper 2 read 

1 » Exhaustion of Brain Energy," Medical Kecord, April 7, 1883, 
vol. xxiii. No. 14. 

2 "Brain Exhaustion," New York Medical Journal, December 
29, 1883. 



THE SPECIAL THEKAPEUTICS OF PAIN. 151 

before the Medical Society of the County of New- 
York, November 26, 1883, I took occasion to enter 
somewhat more into details. For the sake of 
brevity I extract from the above paper the follow- 
ing description of the scheme of cerebral rest pre- 
sented on that occasion : 

The essential features of this system are, 1. Cere- 
bral rest (prolonged sleep); 2. Increased general 
and cerebral nutrition ; 3. Elimination of psychical 
irritation and sensory impressions, particularly those 
of light and sound (isolation of the sensorium). 

General Description of Treatment by Cerebral 
Rest. — The subject is isolated in a darkened room, 
eventually from ten to fifteen hours at a time, ac- 
cording to the amount of sleep which it is desired 
shall be had during the twenty-four hours. The 
amount of sleep is progressively increased by habit, 
hydro-therapy, appropriate food, and moderate med- 
ication. "When I speak of appropriate food, I mean 
such aliments as exert a demonstrably soporific 
effect, such as the various preparations of hops and 
the different kinds of dishes in which lettuce is em- 
ployed as a principal ingredient; hence salads, etc. 
It is impossible to over-estimate the importance of a 
carefully-regulated diet in a system of treatment, 
the corner-stone of which is prolonged sleep, — that 
is, sleep protracted far beyond what is common or 



152 PAIN. 

necessary to the welfare of persons in ordinary 
mental health. In the books which ostensibly treat 
of sleep and its disorders, reference is sometimes 
made to the digestibility of food as related to that 
function. But among the various papers and books 
treating of insomnia which have come under my 
observation I have found no reference to the direct, 
promotive influence exercised by a goodly number 
of aliments upon the function of sleep. The sopo- 
rific effects of some kinds of food are indeed of 
the most striking character, and I feel justified in 
stating, after an extensive experience in these mat- 
ters, that one cannot hope to cope with the ordinary 
problems of insomnia, much less with those pre- 
sented in the course of treatment by prolonged 
sleep, without first thoroughly mastering this aspect 
of the subject. 

As to sedatives and other forms of medication, 
I can only say that I resort to them as little as 
possible. In cases of functional brain-trouble, com- 
plicated by inordinate irritability and worry, I am in 
the habit of giving the bromides in moderate doses 
during the day, with a view of bringing the brain 
into a condition of sufficient tranquillity towards 
evening to render the supervention of sleep possible. 

In conjunction with coca, I have used the prepa- 
rations of absinthe (usually the extract) for the pur- 



THE SPECIAL THEEAPEUTICS OF PAIN. 153 

pose of allaying the worry and depression which 
are at times such distressing features of insomnia, 
cerebral irritation, and exhaustion. On this point I 
shall have something further to say in the section 
devoted to internal therapeutics. I will only add, 
in this connection, that I never attempt, by the 
reckless use of sedatives, to produce that form of 
unconsciousness which has been called sleep, but 
which, after all, bears a far closer kinship to stupor. 

When the patient awakes, which may occur not 
at all or two or three times during the hours set 
apart for rest, nourishment is administered ; but the 
latter is always not only digestibly prepared but, 
what is of hardly less importance, it contains a 
soporific adjunct such as lettuce. 

As a matter of course, the amount of sleep re- 
quired is necessarily not the same in all cases ; in 
a considerable percentage of persons under treat- 
ment, from ten to fifteen hours in the course of the 
day will prove sufficient. I have, however, in 
exceptional cases, prolonged the quotidian period 
of unconsciousness up to eighteen hours ; and in a 
recent case of severe cerebral exhaustion, which 
was referred to me for treatment, I succeeded in 
inducing unconsciousness for a period of twenty- 
one hours out of the twenty-four, and that without 
excessive medication, unless hydrotherapy, soporific 



154 PAIN. 

alimentation, and isolation in a perfectly dark room 
be so denominated. 

At this point in the discussion it will be appropri- 
ate to say a word concerning isolation as I under- 
stand it, which I need hardly say is in a wider sense 
than that usually imputed to the term. 

The Isolation of the Sensorium from its Envi- 
ronment. — The less the exhaustion of the brain- 
cells the greater will be the power of all sensory 
impressions to cause wakefulness. The truth of the 
above proposition has been amply proven by the 
experiments of Kohlschutter. 1 

It is clear, then, since sensory impressions only 
fail to cause wakefulness when the exhaustion 
is great, and hence the state of unconsciousness 
profound, that, therefore, the occurrence of such 
impressions in persons who exhibit but slight pre- 
disposition to unconsciousness must be detrimental, 
if not absolutely fatal, to sleep. As a natural con- 
sequence, it follows that the elimination of sensory 
impressions of all kinds is absolutely necessary if 
we desire to procure protracted sleep for those who 
are "light sleepers," or who are sufferers from 
chronic insomnia. I have been thus explicit in 

1 Messunger der Festigkeit des Schlafes, Inaugural Dissertation, 
von Dr. Ernst Kohlschutter, Leipzig, 1862. See also criticisms 
upon the same in Schmidt's Jahrbucher, 1863, vol. cxviii. 



THE SPECIAL THERAPEUTICS OF PAIN. 155 

order to demonstrate that not only is it expedient, 
as Dr. Mitchell has shown in the case of hysterical 
women, to separate the patient from her friends, in 
order to eliminate the deleterious influences arising 
from ill-judged sympathy, but, what is still more 
important, it is necessary to eliminate peripheral im- 
pressions of all kinds, particularly those arising from 
light and sound. This, of course, is true when we 
desire to obtain cerebral rest for our patient. When 
spinal rest is the object sought after, the chief point 
is, of course, the avoidance of those tactile impres- 
sions which evoke reflex response on the part of 
the cord (the consciousness or unconsciousness of 
the patient being a matter of entirely subsidiary 
importance). When an individual is secluded in 
an isolated and perfectly dark room, it is evident 
that those impressions of light and sound which 
ordinarily attend and usher in consciousness are 
entirely eliminated, so that the brain, if previously 
predisposed to tranquillity by the means to which 
we have already had occasion to refer, may be 
maintained in a state of quiescence for a period of 
far greater duration than is possible under ordinary 
circumstances. It is surprising, indeed, to what an 
extent sleep may be prolonged under these condi- 
tions, especially when, to the other means of per- 
petuating unconsciousness at our disposal, is added 



156 PAIN. 

the subtle force of carefully and progressively culti- 
vated habit. Nothing can exceed the astonishment 
of persons who have submitted to this scheme of 
rest when told of the number of hours which they 
have passed in a state of unconsciousness. It is 
true that after thus oversleeping there is, in the 
beginning, some little mental inertia, — some diffi- 
culty in "getting thoroughly awake;" but this is 
soon dissipated by the aid of a mild sponge- or 
shower-bath, followed by vigorous friction, or by a 
moderate dose of caffeine. 

It now remains to say a word respecting the 
manner in which the patient is to occupy himself 
during the period of wakefulness which succeeds 
the interval of unconscious rest. In the severer 
cases of cerebral irritation, melancholia, and ex- 
haustion, in the treatment of which I employ rest, 
I am in the habit of absolutely prohibiting both 
reading and writing. Any occupation, in fact, 
which causes undue concentration of the intellect- 
ual faculties, or which arouses unpleasant emotions, 
or which predisposes to morbid brooding, is to be 
avoided. A chronic habit of introspection is one 
of the most disagreeable features with which we 
are called to contend when it is a question of 
affording prolonged rest to the sensorium. 

Otherwise to be considered are those amusements 



THE SPECIAL THERAPEUTICS OF PAIN. 157 

which, while diverting the mind from self-consuming 
reflections, do not materially exhaust its energies. 
Gay music, hilarious theatrical representations, — 
these are potent remedies against the insidious 
inroads upon the tranquillity of the mind born 
of chronic introspection and inordinate worry. It 
matters, indeed, little what the character of the 
amusement be so long as indulgence in the same 
is not coupled with late hours, — a characteristic 
which, unfortunately, is inseparable from many 
recreations indulged in by the inhabitants of 
cities. 

The matter of food has already been alluded to, 
in so far as the important group of soporific ali- 
ments is concerned. There are, however, other 
foods of importance to a rational system of cerebral 
rest, — I mean those nitrogenous compounds which 
are indispensable to brain and muscle alike. I have 
already had occasion to point out that experimental 
inquiry has shown that mental work involves the 
consumption of both the nitrates and phosphates, 
and that these observations are supported by direct 
analysis of the chemical constitution of the brain 
itself, so far as such have been attempted. 1 

1 The experiments here referred to are those of Byasson, quoted 
in my monograph on Brain-Exhaustion, D. Appleton & Co., New 
York, 1884, p. 41 et seq. 

14 



158 PAIN. 

While, therefore, it is impossible with the present 
means at our command to elucidate the more inti- 
mate chemistry of cerebral metamorphosis, we are 
clearly justified in inferring that the introduction 
and assimilation of nitrogenous and phosphatic 
compounds is of importance in exhaustive condi- 
tions of the cerebral ganglia. In entire consonance 
with these views is the observation that the amount 
of phosphorus contained in the brain is greatest 
among those of active intellects, and that it in- 
creases in amount with the growth of the indi- 
vidual, attaining the maximum quantity at the 
period of adult life. In the aged, on the other 
hand, the quantity is considerably reduced; and it 
has also been alleged that among idiots the amount 
of phosphorus contained in the brain is much 
below the normal standard (?). 

It is not surprising, therefore, that the flesh of 
animals (or its extracts), eggs, milk, and unbolted 
cereals are the aliments which experience has 
proven to be of the greatest value where a direct 
augmentation of cerebral nutrition is the object 
sought. To these foods may also be added cod- 
liver oil or its preparations, where the fatty tissues 
are imperfectly developed. Should the condition 
of the digestive mechanism preclude the introduc- 
tion of oils by the way of the stomach, they may 






THE SPECIAL THERAPEUTICS OF PAIN. 159 

be injected hypodermically, in doses of from one 
to four drachms; and, in exceptional cases, the 
quantity injected at one time may be increased 
beyond half an ounce, provided the skin is suffi- 
ciently loose to preclude the occurrence of painful 
tension. The injection should, therefore, usually 
be accomplished slowly ; and, in order to avoid the 
needless detention of the physician by the operation, 
I have devised an apparatus which accomplishes 
this injection automatically, the supervision of the 
same being intrusted to the patient himself. 

In cases of profound disturbance of the digestive 
organs there should, of course, be no hesitancy in 
resorting to systematic alimentation per rectum, a 
procedure which may be combined advantageously 
with hypodermic injection of oil. 

This, then, is a brief outline of the system of 
cerebral rest to which I have resorted in the treat- 
ment of a large class of functional cerebral derange- 
ments during the last few years. Of the success 
attending this mode of treatment I will speak in 
guarded terms, lest I should develop a degree of 
enthusiasm which to some might appear inordinate. 
This much I will say, however, that I have em- 
ployed it in the treatment of cerebral irritability 
and exhaustion and in cases of insomnia which 
had resisted all ordinary remedies. I have also had 



160 PAIN. 

recourse to it in the treatment of chorea and the 
first stages of melancholia. 

It would be a conspicuous omission did we fail, 
in concluding this chapter, to give an account of 
the special precautions to be observed in the man- 
agement of the condition of melancholy which is 
often so serious a complication of severe pain. 
While, as previously shown, it is of the greatest 
importance that those who suffer from profound 
depression should be made to sleep, — for only in 
this way can the emotional stress be adequately 
compensated, — it is equally incumbent upon us to 
diminish, as far as possible, the mental pain from 
which such persons suffer during the hours of 
wakefulness. Indeed, it may as well be stated at 
once that our efforts to procure sleep for the pa- 
tient are almost certain to result in failure, unless 
we succeed in abolishing or, at least, relieving his 
melancholy as the time set apart for unconscious 
rest approaches. 

Should there be marked physical pain it must, 
of course, be removed by the application of one or 
several of the expedients to be subsequently dis- 
cussed. Such relief will of itself tend to facilitate 
the occurrence of sleep. Sometimes, however, in 
spite of the exemption from acute physical suffer- 
ing, the mental pain — the melancholia — still persists. 



THE SPECIAL THERAPEUTICS OF PAIN. 161 

This is especially true of those who have borne the 
brunt of a long and painful illness. Under such 
circumstances nothing in the world is comparable 
in efficacy with the judicious use of stimulants 
while the subject remains in a condensed atmos- 
phere, by which we mean air which is compressed 
until it is at least twice as dense as the normal 
atmosphere. The object of this exposure of the 
patient to a condensed atmosphere is to augment 
the action of the previously-administered stimulants 
and to promote the circulation in the cerebro-spinal 
axis, for it is a matter of experience, as I long since 
showed by the statistics of the populations whose 
vocations necessitate a prolonged sojourn in com- 
pressed air, that these remedies, especially those of 
a diffusible character, are materially re-enforced in 
their effects when thus exhibited. 

The stimulants which are best suited to this mode 
of administration are absinthe, caffeine, and alco- 
hol. Although ether might perhaps be added to 
the list, I have purposely omitted it, since, though 
its stimulating properties are greatly enhanced by 
the immersion of the patient in compressed air, the 
exhilaration thus evoked is too evanescent, and is', 
moreover, speedily followed by increased irritability 
and depression. This criticism applies neither to 
alcohol, caffeine, nor absinthe, when medicinally 
i 14* 



162 PAIN. 

employed, by which we understand that the patient 
should not be informed of the nature of the reme- 
dies, and that the latter should be continued no 
longer than seems absolutely necessary, their gradual 
withdrawal being undertaken as soon as there is a 
return of appetite and normal sleep. 

Another extremely important measure in the 
management of melancholia is the stimulation of 
the excretory functions. To this end a sufficient 
cathartic should be given to insure at least one 
operation of the bowels a day ; for nothing is more 
certain than that constipation is of itself quite 
capable of provoking and perpetuating a state of 
mental depression. 

The action of the kidneys, too, should be in- 
creased by the administration of appropriate diu- 
retics, the substance known as diuretin being one 
of the best. 

Finally, it is of very great importance to augment 
the excretory functions of the skin ; for numerous 
observations have shown that in this way foreign 
materials which exert a depressant action upon the 
central nervous system may, in part at least, be 
eliminated. 

To thoroughly appreciate the importance of these 
injunctions, it must be remembered that in melan- 
cholia all the vital processes are more or less cur- 



THE SPECIAL THEEAPEUTICS OF PAIN. 163 

tailed, as revealed by the loss of weight, as well as 
by the inertia of the affective and intellectual facul- 
ties. We have, in a word, to do with a predomi- 
nance of the processes of waste over those of 
integration, with a defective metabolism of which 
the final effect must be the inordinate accumulation 
of waste products in the organism. 

No physician of large practical experience in the 
management of this class of cases will, I believe, be 
inclined to question this exposition of the pathology 
of melancholia. Nor will the conclusion that the 
elimination of these waste products must be thor- 
oughly accomplished — must proceed, indeed, side 
by side with our attempts to build up the devital- 
ized tissues by the aid of appropriate nutrition — be 
gainsaid. 

And let me observe, parenthetically, that the 
effects of some diuretics and diaphoretics, and per- 
haps of all, are notably enhanced by their exhibition 
while the patient remains under a pressure of two 
atmospheres. This fact will be readily understood 
when it is remembered that one of the chief effects of 
compressed air, when used in this way, is to increase 
the blood-pressure in the interior of the organism, 
the blood being driven from the periphery towards 
the centre. The effect of this is, of course, to in- 
crease the action of those nervous mechanisms 



164 PAIN. 

which control the secretory and excretory functions, 
and also to raise the blood-pressure in the organs 
themselves and, notably, in the kidneys and liver. 

In a subsequent chapter the various physiological 
and clinical data connected with the employment of 
compressed air in the treatment of melancholia and 
pain, notably that of intracranial origin, will be dis- 
cussed in full, so that, having anticipated enough in 
the present chapter to render the argument intelli- 
gible, we must beg permission to leave the subject 
for the present, avoiding thereby needless repetition. 

Finally, the good effects sometimes obtainable 
from the use of moderately cold shower-baths are 
not to be ignored. It must not be forgotten, how- 
ever, that this mode of treatment is admissible only 
when the condition of the heart and circulation 
is such as to insure a proper reaction, — i.e., in- 
creased redness of the lips and skin, a diminution 
of the feeling of malaise, accelerated heart-beat, 
and at least a temporary disappearance of apathy. 

It need hardly be added that the diversion of the 
patient, in every possible manner, and his eventual 
exposure to changes of scene and climate, — but the 
latter only after he has proceeded well along the 
road to recovery, — are things which render valu- 
able assistance in confirming the good work accom- 
plished by more direct measures. 



CHAPTER XL 

OP INTERNAL REMEDIES WHICH ARE EITHER DIRECTLY OR 
INDIRECTLY APPLICABLE IN THE TREATMENT OF PAIN. 

From what has previously been said regarding 
the causation and collateral phenomena of pain, it 
is evident that the remedies which are applicable 
in its management are manifold. They include, in 
the first place, a large number of substances broadly 
and somewhat roughly classified as nervous seda- 
tives and stimulants ; secondly, a somewhat smaller 
category of analgesics which are, strictly speaking, 
perhaps neither sedatives nor tonics; and, thirdly, 
chemicals which are supposed to effect more or less 
profound changes in the morphological process, — 
the so-called alteratives. 

It will be well to bestow a glance upon the more 
important of these remedies. 

Nervous Sedatives. — In this category belong 
those agents which exert a depressing effect upon 
the cerebro-spinal axis, the brain being often that 
portion of the nervous system most obviously af- 
fected. Narcotic substances are representative of 
this class of remedies. 

165 



166 PAIN. 

Opium and its derivatives constitute, in some 
respects, the most important remedies which we 
possess for combating painful paroxysms of great 
severity. Physiologists are by no means agreed 
as to the manner in which opium exercises its 
effects upon the organism. Thus, some writers of 
distinction assert that it is a sedative pure and sim- 
ple, while others insist that it is to be regarded as 
a stimulant. The truth of the matter is, however, 
that its action may be both sedative and stimulant, 
the diversity of physiological effect being in great 
measure contingent upon the difference in the mag- 
nitude of the dose. Thus, small doses are produc- 
tive in most instances of marked stimulating effects, 
whereas large ones are sedative in their action. 

The hypnotic property of opium has been as- 
cribed by some to its influence in lessening the 
amount of blood in the brain; but, for my own 
part, while fully recognizing the importance of the 
circulatory phenomena induced, I cannot forbear the 
conviction that the latter are of purely secondary 
origin, being in the main attributable to the primary 
action of the drug upon the substance of the brain. 
This ability of the drug to retard cerebral meta- 
bolism is the essential feature of hypnosis. 

It would transcend the limits and objects of the 
present work were I to enter into a discussion of 



THE SPECIAL THERAPEUTICS OF PAIN. 167 

the various conflicting opinions which have been 
advanced from time to time as the result of exten- 
sive experimentation. Much of the discrepancy in 
the nature of these results is doubtless attributable 
to variation in the size of the dose, as well as to 
fluctuation in the quantity of the very numerous 
active principles contained in the drug. No less 
than nineteen different alkaloids have been sepa- 
rated from this exceedingly complex substance, so 
that, in introducing the crude drug into the system, 
we necessarily have to do with an aggregate effect 
of all of them. In their relative therapeutic value, 
however, the alkaloids of opium differ widely ; but, 
if extensive applicability as an analgesic be a cri- 
terion of excellence, pre-eminence must unquestion- 
ably be ascribed to morphine. 

The stimulating effects of morphine upon the 
circulation and central nervous system are not as 
pronounced as those of opium, and its soporific in- 
fluence is also less positive. The anodyne effects 
of opium and morphine are so thoroughly under- 
stood as to render even a reference to them almost 
superfluous in a work of this kind. We are, how- 
ever, too liable to forget that previous to the intro- 
duction of chloral, the bromides, and the coal-tar 
derivatives, opium occupied the highest position in 
the treatment of all forms of insomnia, and that 



168 PAIN. 

even at the present day, in spite of the great prog- 
ress made in pharmacy, the poppy may sometimes 
be invoked as a soporific medicine. When com- 
bined with one or more of the modern remedies, 
such as chloral, the bromide of potash, and hyos- 
cyamus, the result is a preparation possessing unique 
virtues in the management of certain cases of in- 
somnia. 

Where there is severe pain, as in tic douloureux 
and other aggravated forms of neuralgia, preference 
should, of course, be given to morphine, adminis- 
tered in conjunction with atropine, — one-hundredth 
of a grain of atropine to a quarter of a grain of 
morphine. In the delirium of fevers and mania, in 
insomnia preceding various forms of insanity, as 
well as in the wakefulness due to the various acute 
and chronic diseases, morphine often renders inval- 
uable assistance. 

In spite of the extensive abuse in the use of alco- 
hol, which has become such a crying evil of modern 
social life, it must be admitted that this is a most 
useful remedy in the management of a large num- 
ber of painful conditions associated with anaemia. 
For this reason a knowledge of its more obvious 
physiological effects is essential to its intelligent 
employment. 

When used in moderation, alcohol is absorbed by 



THE SPECIAL THERAPEUTICS OF PAIN. 169 

the tissues with benefit, contributing in a certain 
degree to the nutrition of the latter, and causing a 
sensation of exhilaration. The effects produced by 
its excessive use are, however, quite different. 

Under these circumstances the normal chemistry 
of the tissues is profoundly deranged; their func- 
tions are interfered with ; and, as an ultimate result, 
the characteristic phenomena of starvation become 
established. The functions of the nervous system 
which are disturbed by the presence of an excessive 
amount of alcohol in the blood and tissues are those 
of voluntary motion, reflex action, and sensation. 
Small doses of alcohol produce more or less stimu- 
lation of the cerebro-spinal functions, and, as a con- 
sequence, moderately painful sensations, especially 
those of intracranial origin, are speedily relieved. 
The secretory functions, too, are exalted, as shown 
by increased secretion of saliva and perspiration. 
The heart-beat is also increased in frequency, and 
the skin, especially about the head, becomes suffused 
with blood. Respiration is also more or less accel- 
erated; the eyes glisten because of the increased 
lachrymal secretion, and the pupils are slightly con- 
tracted. In consequence of the general nervous 
exaltation the individuals desire to move about, and 
even to dance and run. For a time there is con- 
siderable hyperesthesia of the special senses; the 

H 15 



170 PAIN. 

acuity of perception is increased ; ideation is more 
vivid; and, in a word, all the intellectual faculties 
are exalted. As may readily be imagined, the emo- 
tions participate in the general exhilaration; im- 
moderate laughter is engendered upon the slightest 
provocation, and the dominant psychical peculiarities 
of the individual become conspicuous. At the same 
time the reasoning faculties lose their restraining 
influence, and the inhibitory effects of conscience 
and experience are thrown to the winds. These 
are the typical manifestations engendered by mod- 
erate doses of alcohol, subject, of course, to tem- 
peramental variations. When, however, the amount 
ingested is large, the primary exaltation gives place 
in a short time to all the symptoms of depression ; 
co-ordination is impaired; the gait becomes un- 
certain ; articulation is interfered with ; and ideation 
becomes confused and incoherent. At length sensa- 
tion and motion become impossible, consciousness 
is suspended, and the patient lies in a state which is 
practically comatose. 

Though at first sight the physiological explana- 
tion of such heterogeneous symptoms impresses one 
as little short of impossible, a more careful analysis 
shows that they can all be traced to the inhibitory 
or paralyzing action of alcohol, when present in 
animal and vegetable protoplasm. 



THE SPECIAL THERAPEUTICS OF PAIN. 171 

The action of alcohol upon the circulation is a 
matter of profound practical interest from a thera- 
peutic point of view; and this is especially ex- 
emplified by functional affections of the nervous 
system, in which the condition of the vaso-motor 
system is often a factor of some importance. With- 
out entering into the intricacies of the subject, it 
may be stated in general terms that the first effect 
of alcohol upon the circulation is to cause increased 
arterial pressure : the muscular coats of the ar- 
teries are contracted, and the diameter of the ves- 
sels consequently reduced. These primary effects 
are, however, of brief duration, for in a short time 
the increase in arterial pressure is followed by a 
corresponding decrease ; the relaxation of the vessels 
becomes universal, and, at the same time, the energy 
of cardiac action is diminished. These phenomena 
are in themselves of the greatest importance, and 
their interest to the neurologist is enhanced from 
the fact that the circulation of the cord and brain 
— particularly the latter — is pre-eminently affected. 

The hypersemic condition evoked by alcohol is 
evidently due to the paralyzing action of this agent 
upon the terminal (peripheral) apparatus of the 
vaso-motor nerves. This terminal apparatus, as is 
well known, is situated in the walls of the vessels 
themselves. 



172 PAIN. 

It is evident from the foregoing data regarding 
its physiological effects that alcohol possesses pecu- 
liar advantages in the treatment of a variety of 
painful intracranial conditions characterized by the 
presence of more or less ansemia. The insomnia, 
too, which so frequently accompanies general anae- 
mia, is readily relieved by its administration in 
moderate doses. "When, however, the relief of 
severe neuralgia is in question, large doses alone 
are applicable, as may readily be deduced from 
what has previously been said. This question of 
correct dosage has indeed given rise to much con- 
troversy, as is abundantly shown by the discrep- 
ancies of opinion prevalent in current literature 
and the special treatises on therapeutics. While it 
is difficult to enunciate rules which shall cover the 
exigencies arising in all cases, it may be stated in 
general terms that where stimulating effects are 
required moderate doses (from four to five drachms 
of spirits), repeated at regular intervals, are indi- 
cated. On the other hand, when the principal 
object of treatment is to cause relaxation of the 
cerebral blood-vessels, the doses should be full. It 
is impossible, however, to lay down infallible rules 
of exhibition on account of the variable suscepti- 
bility of different persons, and hence the symptoms 
of the patient should be studied and the quantity 



THE SPECIAL THERAPEUTICS OF PAIN. 173 

increased until there is well-marked throbbing 
of the carotids and flushing of the face and con- 
junctiva. 

Inhalation of ether is sometimes employed to 
mitigate the atrocious pain of tic douloureux. Its 
effects are, however, evanescent in character, owing 
to the rapidity with which this agent is eliminated 
from the system through the lungs, and hence the 
expedient can never replace remedies introduced 
into the system in solution, and which, owing 
to their gradual elimination from the organism, 
exert an analgesic influence for relatively long 
periods of time. These objections do not apply 
to the same extent to the internal administration 
of ether in the form of Hoffmann's anodyne, which 
is a mixture of alcohol, ether, and ethereal oil. 
This preparation may be exhibited in doses of from 
one-half to one drachm, to be repeated every half- 
hour or offcener, till physiological effects are ob- 
tained. The same objections which apply to inha- 
lations of ether hold good in the case of chloroform, 
and hence by far the most serviceable mode of 
administration is in the form of chlorodyne, a prep- 
aration which has long held a deservedly high place 
in the esteem of the profession, both in this country 
and England, where it was first introduced by Dr. 
Browne. 

15* 



174 PAIN. 

Among the general nervous sedatives the bro- 
mides occupy a deservedly high place. It must be 
confessed, however, that while they are capable of 
relieving minor grades of intracranial pain, due to 
passive engorgement, their analgesic powers are 
not sufficient to cope with even moderately severe 
peripheral neuralgia. Still, they render a certain 
amount of assistance in the management of nervous 
irritability and other collateral effects of pain. The 
physician should, therefore, be equipped with a 
general knowledge of their physiological effects in 
order to employ them intelligently. 

The bromide of potassium is, strictly speaking, a 
general nervous sedative rather than an hypnotic; 
and consequently it may be employed with advan- 
tage in allaying irritability of the brain, spinal cord, 
and sexual system. In this way it may indirectly 
induce sleep. 1 Of this something more will be said 
hereafter. 

It seems clear, indeed, that the bromide of potas- 
sium exerts its sedative action in a twofold manner : 
1, by causing a diminution in the intensity of the 
vital processes of the ganglia; and, 2, by causing 
more or less retrocession of the intracranial blood. 

1 On the Action of Medicines in the System, by Frederick Wil- 
liam Headland, M.D., Philadelphia, 1878. 



THE SPECIAL THERAPEUTICS OF PAIN. 175 

Even the most superficial knowledge of cerebral 
physiology will serve to exhibit the importance of 
a remedy which combines two such valuable quali- 
ties. The potency of the bromides in the treatment 
of epilepsy and other irritable and explosive condi- 
tions of the nervous system is undoubtedly attribu- 
table to this duality of effect. 

The soporific energy of the bromides may be 
ranked, approximately, as follows : 

Bromide of potassium first, bromide of lithium 
second, and bromide of sodium third. 

It is clear, then, from their action, that the bro- 
mides find their chief application in irritable ex- 
plosive and exhaustive conditions of the central 
nervous system. They have also been largely em- 
ployed in the treatment of insomnia due to worry 
and morbid emotionality. I am convinced, how- 
ever, that we should exercise caution when thus 
resorting to them, in order to avoid the depression 
which follows a too copious administration. 

The insomnia of sexual excitement, of mania, of 
hysteria, of cerebral exhaustion and cerebral irri- 
tability, may be combated effectively by the ad- 
ministration of the bromides in conjunction with 
hypnotics. It is necessary to bear in mind, how- 
ever, that the bromides should be given repeatedly 
during the day, beginning in the afternoon at two 



176 PAIN. 

o'clock and continuing the dose every hour until 
shortly before retiring. We may then supplement 
the sedative action of the bromides by a moderate 
dose of some hypnotic, such as trional or chloralamid. 
In persons who suffer from general and local anae- 
mia it may happen that, instead of promoting sleep, 
the bromides serve only to augment the insomnia. 
Under these circumstances alcohol should be given 
in quantities sufficient to cause slight flushing of 
the face. Should these measures prove ineffectual, 
ten to twenty drops of the tincture of opium may 
be added, or the tincture of hyoscyamus (two 
drachms) with chloral (fifteen grains). The dose 
of the bromides which is required to produce the 
characteristic sedative effect varies much more than 
is commonly supposed. Thus, cases are seen in 
which ten grains of the potassium salt were suffi- 
cient to produce drowsiness. Such cases must, 
however, be regarded as somewhat exceptional, 
since in most subjects scruple doses of the lithium 
and potassium salts may be repeated every hour or 
two until hebetude is pronounced. When a rapid 
sedative effect is required the dose may be increased 
to thirty, forty, or sixty grains ; and this applies to 
the sodium and calcium salts as well as to the 
bromides of lithium and potassium. 

Hydrobromic acid has also been employed to 



THE SPECIAL THERAPEUTICS OF PAIN. 177 

some extent as an hypnotic, in doses of from twenty 
to thirty grains, diluted with a sweet, aqueous vehi- 
cle of some kind. On account of its offensive taste, 
however, it is not a preparation which is destined to 
occupy a place of much importance. 

Gelsemium was formerly considerably employed 
in the treatment of pain, but of late, since the in- 
troduction of the coal-tar derivatives, its use has 
been much restricted. The extremely poisonous 
effects of the plant, which make their appearance 
suddenly, and often without ascertainable cause, 
have had much to do with this. 

Nervous Stimulants. — It now remains to consider 
briefly those substances which exert a demonstrably 
stimulating effect upon the central nervous appa- 
ratus. As is well known, some of these agents 
may be both sedative and stimulating in their ac- 
tion, according to the size of the dose and other 
circumstances of administration. This duality of 
effect is particularly exemplified in the case of 
opium, as we have already had occasion to observe 
when considering the sedative properties of that 
drug. Although we are most frequently called 
upon to invoke the sedative property of the drug 
in the management of painful conditions, it must 
nevertheless be conceded that under some circum- 
stances its stimulating properties are capable of 



178 PAIN. 

rendering substantial assistance. This is especially- 
true of pain which is associated with well-marked 
debility; for, as has already been pointed out, the 
nervous system — though, perhaps, the last to share 
the impairment consequent upon such malnutrition 
— ultimately suffers with the rest of the organism, 
and hence measures specially directed to the re- 
habilitation of its functions are indicated. 

Cannabis Indica is a remedy of the same order, 
its effects being conspicuously exerted upon the 
central perceptive mechanism, which is stimulated, 
perverted, or exaggerated in various ways, accord- 
ing to individual susceptibility. In most persons 
its most obvious effect is an agreeable intoxication. 
The mental faculties are exalted; the subject laughs 
in an inordinate, hysterical manner, and becomes 
unusually loquacious ; while the countenance wears 
a beatific expression, indicative of the satisfaction 
which reigns within. The flow of ideas is stimu- 
lated to an inordinate degree, and as a consequence 
the thoughts are disconnected and wholly irrelevant, 
as indicated by rapid and incoherent utterances. 
Sometimes surrounding objects — such as articles of 
furniture — assume unusual shapes, and thus verita- 
ble illusions are developed. Sometimes the sexual 
functions are excited, and the gestures, facial ex- 
pression, and conversation are of the most libidi- 



THE SPECIAL THERAPEUTICS OF PAIN. 179 

nous character. Sensibility may also be affected; 
and there may be sensations of numbness and 
pricking in the soles of the feet, accompanied, in 
some instances, by burning, when pressure is ap- 
plied to the integument. Sometimes, too, there 
may be ansesthesia of such intensity as materially to 
interfere with all attempts at locomotion, the sub- 
ject, while standing, being totally unconscious of 
the presence of his feet upon the ground. It may 
readily be imagined that an agent which possesses 
such qualities is capable of rendering substantial 
assistance in the management of pain. And, in- 
deed, experience has shown that, when it is admin- 
istered in sufficient quantities to produce these 
phenomena, a variety of painful conditions, and, 
notably, certain headaches, may be ameliorated and 
sometimes permanently abolished. When, how- 
ever, its administration is still further increased, 
sleep may be produced, but a sleep so far removed 
from the normal prototype, accompanied as it is by 
delirium and morbid cerebral erethism, that its 
exhibition in this manner is not usually to be com- 
mended. But it is a noteworthy circumstance that 
its usefulness is appreciably enhanced by combina- 
tion with opium, belladonna, or hyoscyamus, and 
when thus administered its effects are often most 
happy, since it promotes the tolerance of the sys- 



180 PAIN. 

tern to opiates, and probably supplements their 
action. Cannabis Indica, then, has a wide range 
of applicability in the management not only of 
pain, but of the collateral nervous disturbances of 
that condition as well. Thus, it has been employed 
in the different varieties of insomnia, neuralgia, 
headache (migraine), and convulsions. In head- 
aches of a local character, accompanied by sensa- 
tions of throbbing and lachrymation, it has been 
highly spoken of by Ringer, and I have frequently 
had occasion to verify its efficacy in this connection. 
It must be remembered, however, that all persons 
are by no means affected in an identical manner; 
and, consequently, too much should not be antici- 
pated from its employment on purely a priori 
grounds. Race, climate, and constitutional idio- 
syncrasy have all been cited from time to time as 
affording the true explanation of this inconstancy 
of action; but it must be conceded that such 
theories are not altogether explanatory. In the 
face of such discrepancy, then, empiricism is our 
best guide; and the use or abandonment of the 
drug in a given case may safely be decided by the 
results obtained by careful trial. As all practi- 
tioners are aware, the large and variegated group 
of symptoms included under the name of hysteria 
are often relieved by the administration of valerian. 



THE SPECIAL THERAPEUTICS OF PAIN. 181 

Ringer has found it useful in relieving hot and cold 
perspiration, flushing of the face, and the restless- 
ness and mental depression so often found among 
neurotic persons. As an antispasmodic it has also 
been used in chorea and whooping-cough, and oc- 
casionally mild neuralgia has been relieved by it. 
It must be confessed, however, that its effects upon 
pain are slight, and not to be relied upon. 

Belladonna has long been employed in neurologi- 
cal medicine in the most diverse conditions. Owing 
to a lack of comprehension of its somewhat com- 
plicated physiological effects it has also been much 
abused ; and I believe, therefore, that it will not be 
time misspent if we examine somewhat in detail 
the knowledge of its action, which has been gained 
by most elaborate experimental investigation. 

Belladonna or its alkaloid, atropine, when intro- 
duced into the system subcutaneously or by the 
mouth, increases the irritability of the gray sub- 
stance of the spinal cord. This influence is especially 
pronounced in the domain of the vaso-motor centre, 
and respiration as well as the action of the heart 
is appreciably increased. It has been found, how- 
ever, that belladonna does not act in the same 
manner upon the heart of the dog as upon that of 
man. According to some observers the pulsations 
of the heart in frogs are not increased after the 

16 



182 PAIN. 

administration of this substance; neither is there 
any appreciable dilatation of the pupil. After con- 
siderable doses of belladonna there is marked dimi- 
nution of muscular power ; this effect is particularly 
manifest in the gait, which becomes uncertain and 
staggering. So great may this weakness become 
that the subject is absolutely unable to direct his 
movements, and staggers about like a person labor- 
ing under the influence of alcoholic intoxication. 
When the amount of the drug absorbed by the 
system is sufficiently large, these phenomena may 
develop into complete paralysis. The muscles of the 
trunk are first affected ; then the terminations of the 
pneumogastric in the heart and lungs become im- 
plicated ; and, finally, the endings of the secretory 
nerves of the salivary and sweat glands and the termi- 
nations of the nerves supplying the iris are involved. 

Flushing of the face, dryness of the mouth, 
tongue, pharynx, and larynx, dilatation of the pupil, 
and a certain bright appearance about the eyes are 
among the more obvious phenomena evoked by full 
doses of belladonna. 

The effects produced upon the mental faculties are 
often grotesque, and at times alarming. Sometimes 
the subject labors under the influence of extreme 
restlessness. He wanders about, paces to and fro in 
a nervous, excitable condition; and, in a word, he is 



THE SPECIAL THERAPEUTICS OF PAIN. 183 

impelled to keep constantly moving, in spite of a 
strenuous desire to remain quiet. At the same time 
the intellectual faculties keep pace with the motor 
excitement ; ideas come and go with great rapidity, 
but are at first connected, — a quality which they 
afterwards lose. Sometimes, too, the movements of 
the patient appear to be governed by a species of au- 
tomatism which induces the constant repetition of 
the same gesture. These movements savor often of 
the trade or occupation of the patient. Thus, I know 
of a shoemaker who, under the influence of large 
doses of belladonna, executed with great precision 
the movements peculiar to his calling, a process 
which was sometimes continued for an hour or more. 

The exalted condition of the mental faculties is 
progressively increased; the rapidly evolved but 
previously connected ideas become more and 
more incoherent, and gradually give place to hal- 
lucinations and a condition of delirium — sometimes 
characterized by acts of violence — necessitating the 
employment of restraint. 

Sometimes mental disturbances of this character 
may result from comparatively insignificant doses ; 
so that too much care cannot be exercised in order 
to ascertain the susceptibility of the subject. Pain 
in the head — over the forehead or in the eyes — is a 
frequently observed symptom after moderate doses ; 



184 PAIN. 

and tinnitus may accompany it, giving rise to the 
opinion on the part of the patient that he is under 
the influence of quinine. A scarlet rash about the 
joints has sometimes been observed after poisoning 
by belladonna; but this symptom is not very 
characteristic. 

To give all the therapeutic indications of bella- 
donna would exceed the objects and scope of the 
present work; I shall, therefore, only refer to the 
more important applications of the drug. 

Aside from its usefulness in the treatment of 
epilepsy and profuse perspiration, which possess less 
interest for us, belladonna has been employed to 
check the paroxysms of whooping-cough, urinary in- 
continence, and chronic inflammation of the spinal 
cord. Brown-Sequard is its chief exponent in the 
last-named connection, basing his advocacy on the 
belief that it causes contraction of the small vessels 
of the cord. Belladonna has long been used in the 
treatment of a wide range of painful affections, and, 
notably, in combination with morphine and codeine. 

The paroxysms of asthma, too, are often arrested 
by belladonna. It must be confessed, however, that 
many instances are recorded in medical literature 
in which belladonna has failed to afford the results 
anticipated from it, chiefly because it was given in 
too small doses. As Ringer long since observed, it 



THE SPECIAL THERAPEUTICS OF PAIN. 185 

may be necessary to give as much as ten minims 
of the tincture every two or three hours, in order 
to allay the discomfort of chronic asthmatics. 

The physiological effects of stramonium are quite 
similar to those of belladonna, and, like the latter, 
it has been much employed in bronchial spasms 
and nervous asthma. It is not directly soporific in 
its action, but, when employed as above indicated, 
it promotes sleep indirectly, by allaying irritative 
symptoms which prevent unconsciousness. As is 
well known, the effects of the drug are best ob- 
tained by smoking. 

Fifteen or twenty grains of the dried leaves, or 
ten of the powdered dried root, are placed in an 
ordinary pipe, and the smoke is slowly inhaled. 
The addition of tobacco has been suggested; but 
only persons thoroughly habituated to the use of 
the drug are able to inhale the latter without great 
discomfort. This is especially true of children and 
delicate women, who are frequently thrown into 
violent paroxysms by crude attempts of this kind. 
Some of the medicated pastilles found in the shops 
may occasionally serve as substitutes for the dried 
leaves ; the practice of mixing the latter with salt- 
petre and allowing them to be slowly consumed 
while the fumes are inhaled is a time-honored ex- 
pedient, but decidedly inferior to smoking. 

16* 



186 PAIN. 

Strychnine is a remedy which has long been used 
in the treatment of various atonic conditions of the 
spinal cord. From this it may be readily inferred 
that its effects manifest themselves principally in 
the domain of this structure, the irritability of the 
cord being increased by its administration. When 
a large quantity of the remedy is introduced into 
the system symptoms which bear the closest resem- 
blance to those of tetanus are evoked. These phe- 
nomena are exhaustively discussed in the systematic 
treatises, so that nothing further need be said of 
them. 

Strychnine is especially useful in the treatment 
of spinal irritation and other painful conditions due 
to nutritive derangements of the cord. 

Calabar bean and its alkaloid, physostigmine, are 
opposed in their action to that of strychnine, and 
hence they may be employed with good effect in 
case of poisoning by that drug, as well as in tetanic 
spasms from other causes. In all cases of pain, 
therefore, where it is desirable for any reason to 
diminish the irritability of the cord, physostigmine 
may confidently be exhibited. 

The physiological effects of physostigmine have 
been most thoroughly investigated by Dr. Fraser. 
Did the scope of this work permit I should be glad 
to quote these experiments in full, but, on account 



THE SPECIAL THERAPEUTICS OF PAIN. 187 

of the limited space available, I shall be obliged to 
summarize them briefly, as follows : 

When physostigmine is introduced into the system 
it gradually diminishes and finally destroys the irri- 
tability of the gray substance of the spinal cord. 
It also causes a diminution of the number of the 
heart's contractions when given in moderately large 
doses; and when the amount of the substance in- 
troduced into the system is considerable cardiac 
action is almost immediately arrested. Large doses 
of physostigmine also cause paralysis of respiration. 

If, after introduction of the poison into the sys- 
tem, the galvanic current be applied to the vagus, 
it will be found that a weaker current is required 
to arrest the action of the heart than when the 
animal is in health. 

From what has been said it is evident that Cala- 
bar bean is rather a sedative than a stimulant; but 
I have referred to it in this place because of its 
antagonistic action to that of strychnine. 

Quinine, phosphorus, zinc, and arsenic are among 
the valuable tonics which have been employed in 
the treatment of a large number of painful condi- 
tions characterized by marked debility of the ner- 
vous system. Quinine is especially useful in the 
treatment of those painful conditions due to mala- 
rial influences. This is well exemplified in its rapid 



188 PAIN. 

curative action in supraorbital neuralgia due to 
malaria. There are, however, besides these brow- 
pains, others which do not yield to even the largest 
doses of quinine, a fact which has not been suffi- 
ciently accentuated in the books. 

By promoting metamorphosis in the tissues phos- 
phorus increases the intensity of the vital processes, 
and much of the benefit incident to its administra- 
tion is doubtless due to this fact. It must not be 
forgotten, however, that if such benefits are to be 
permanently realized the general nutrition must 
be augmented to such a degree as to compensate 
for the destructive changes in the tissues which are 
inevitable when phosphorus is present in consider- 
able quantities in the organism. 

Though the manner in which zinc exercises its 
effects is less obvious, its use in the clinic has shown 
it to be of very considerable value as a tonic. This 
is especially shown by its almost specific effects in 
many cases of chorea. 

Arsenic, too, has likewise been employed in the 
treatment of a number of painful affections of pe- 
ripheral origin, and notably in sciatica and in the 
ambulatory pains sometimes encountered in choreic 
children. Its specific effects upon the irregular 
movements of St. Vitus's dance are too well known to 
the profession to require more than cursory mention. 



CHAPTER XII. 

OF OTHER AND MORE RECENT REMEDIES WHICH HAVE BEEN* 
EMPLOYED IN THE TREATMENT OF PAIN. 

During the past few years a number of new sub- 
stances have been added to organic chemistry, some 
of which have certainly proved themselves to be of 
great value in the treatment of pain. Some of these 
bodies have been obtained directly from coal-tar, 
and hence they are known in the shops as the coal- 
tar derivatives. Others, again, are the reward of 
only the most elaborate and ingenious synthesis. 
It is not a matter of surprise that the Teutonic 
mind, with its resourceful vigor and tenacity of 
purpose, should have been chiefly instrumental in 
giving us these new and valuable remedies. 

Obviously, a short resume of the salient character- 
istics of the more important of these new analgesics 
is indispensable to completeness of statement. 

Antipyrin, first produced by Knorr, of Erlangen, 
is an antipyretic and analgesic of very great value. 
It has a number of scientific designations, of which 
dimethyloxyquinizin is the least_* polysyllabic. Anti- 

189 



190 PAIN. 

pyrin is soluble in water and chloroform, less so in 
ether. On account of its depressant influence on 
the heart's action it is best given in half a tumbler 
of water to which a teaspoonful of the aromatic 
spirit of ammonia has been added. 

As a rule, doses of from ten to thirty grains will 
be found sufficient. 

Antipyrin is one of the most universally applica- 
ble analgesics which we possess. It has been em- 
ployed with success in the various forms of neuralgia, 
spinal irritation, headache, and tubercular meningi- 
tis. In the last-named affection I have injected it, 
in combination with cocaine, directly into the spinal 
canal. For the technical points involved in the 
last-named procedure see the subsequent chapter on 
local medication of the cord. Even the pains of 
locomotor ataxia, labor, and those of cancer and 
dysmenorrhea have been relieved by it. When 
given hypodermically it acts much more rapidly, 
and hence its exhibition in this way has been rec- 
ommended in angina pectoris, renal and biliary 
colic, and dysmenorrhea. 

Phenacetin, like antipyrin, is a derivative of coal- 
tar. It is likewise known in the technical litera- 
ture of chemistry as acetophenetidin. Phenacetin is 
sparingly soluble in cold water, somewhat more so 
in boiling water, and quite soluble in alcohol. It 



THE SPECIAL THERAPEUTICS OF PAIN. 191 

is, perhaps, best given in cachets, in doses of from 
ten to fifteen grains. 

Though inferior to antipyrin in rapidity and 
certainty of effect, phenacetin is, nevertheless, an 
analgesic and antipyretic possessed of special ad- 
vantages. In the first place, it has, in addition to 
its anodyne qualities, a sedative and soporific action, 
which is often most useful where we have to deal 
with pain accompanied by marked restlessness and 
extreme irritability. In such cases the mere re- 
moval of the pain is not always sufficient to induce 
sleep, though, of course, a desideratum of the first 
importance. Consequently, a supplementary sopo- 
rific action is required, and this, in the case of phe- 
nacetin, is afforded by the drug itself; whereas the 
same cannot be said of antipyrin, the administration 
of which, while usually followed by relief from 
pain, is more likely to engender wakefulness than 
sleep. 

Phenacetin has been extensively employed as an 
analgesic in the milder kinds of neuralgia and 
migraine ; and it has also rendered good service in 
the treatment of pain of rheumatic origin. In the 
last-named affection it has been advantageously com- 
bined with salol in tablets, which have obtained a 
wide currency, and are now probably well known 
to all practitioners. 



192 PAIN. 

Exalgin is closely allied in its structure to acetan- 
ilid. It is, in fact, methyl-acetanilid, a compound re- 
sulting from the interaction of monomethyl-anilid 
and acetyl chloride. Though quite soluble in alco- 
hol it is only sparingly so in water, and hence it is 
usually given in cachets, in doses of from two to six 
grains. 

As an analgesic, antipyretic, and antiseptic, exal- 
gin has obtained some reputation, chiefly because 
its administration is devoid of such unpleasant 
symptoms as irritation and rash. It must be ad- 
mitted, however, that when the dose is carried be- 
yond the bounds of prudence, trembling and even 
paralysis of respiration may be induced. 

Salol is the phenyl ether of salicylic acid, or, to 
express it more simply, it is the salicylate of phenyl. 

The white, crystalline appearance of this sub- 
stance is doubtless familiar to the majority of phy- 
sicians. 

Though insoluble in water, salol dissolves with- 
out difficulty in alcohol, the fixed oils, and ether. 
It is best given in milk or cachets. The dose is 
from five to thirty grains. 

A noteworthy circumstance in connection with 
its exhibition is the fact that it passes unaltered 
through the stomach, — so that digestion is unaf- 
fected by it, — and only becomes split up into its 



THE SPECIAL THERAPEUTICS OF PAIN. 193 

phenyl and salicyl elements in the duodenum by 
the action of the pancreatic juice. Both alone and 
in combination with phenacetin it has been em- 
ployed as an analgesic ; but its chief field of useful- 
ness is acute rheumatism, where it frequently acts 
with remarkable promptness. 

Besides many pains of rheumatic origin, which 
are promptly relieved by the administration of salol, 
neuralgia of the eyeball and even earache have 
been subdued by it. 

Salipyrin, as its name implies, is a chemical com- 
bination of salicylic acid and antipyrin. It is a 
white, crystalline substance, little or not at all solu- 
ble in water, but dissolving readily in alcohol, and 
may be exhibited in doses of from fifteen to thirty 
grains. In my opinion, not more than seventy-five 
grains should be given in the course of twenty-four 
hours. From its composition the conclusion is 
almost inevitable that salipyrin must be a useful 
remedy in a large category of painful affections, 
among which those of rheumatic origin are not the 
least. What I have been able to ascertain of its 
efficiency by trial in the clinic has convinced me that 
these conclusions are fully justified. In fact, sali- 
pyrin seems to possess a unique value as a means of 
combating those ambulatory pains whose origin is 
often so obscure, but whose capacity for engender- 
i n 17 



194 PAIN. 

ing distress in the patient and annoyance in the 
physician is so positive. 

These observations are especially applicable in the 
case of that protean distemper, the "grippe" (in- 
fluenza), the pains of which are readily controlled 
by the administration of salipyrin, in doses of 
twenty grains every three or four hours. 

"When giving it in this way it is well to counteract 
its depressing effect on the heart's action by the 
simultaneous exhibition of a heart tonic. I usually 
employ for the purpose a tablet of strychnine, spar- 
teine, and digitalis. 

Salophen contains over fifty per cent, of salicylic 
acid; and its efficacy in rheumatic affections, and 
especially in acute rheumatic arthritis, is doubtless 
attributable to this fact. The small, white crystals 
in which it occurs are quite soluble in ether and 
alcohol. As a rule, from ten to fifteen grains are 
a sufficient dose, and the daily maximum amount 
should not greatly exceed sixty or seventy grains. 

Solanine is a glucoside derived from the Solanum 
nigrum and other Solanacese. The crystalline powder 
in which it occurs is practically insoluble in water, 
but dissolves in hot alcohol. As an analgesic sola- 
nine has been highly praised by some authors, hav- 
ing on several occasions afforded prompt relief in 
neuralgia of considerable severity. 



THE SPECIAL THERAPEUTICS OF PAIN. 195 

The dose of the glucoside is from one-fifth to one 
grain, and may be exhibited either in tablet form 
or as a powder. 

Where hypodermic administration is desirable the 
hydrochloride should be employed in like doses. 

Thymacetin is a derivative of thymol, and is 
nearly related to phenacetin, which it also resembles 
quite closely in its physiological action. Occurring 
as a white, crystalline powder, it has been used, in 
doses of from four to fifteen grains, as an analgesic 
and hypnotic. Doses of from eight to ten grains 
are usually sufficient to cause drowsiness. 

Urethane, a carbonate of ethylic ether, occurs in 
colorless, prismatic crystals, is soluble in diluted 
alcohol, and is used principally as a hypnotic and as 
an antagonist to the convulsions of tetanus. In the 
last-named role it is said to be decidedly more potent 
than chloral. Its analgesic properties are, however, 
quite subordinate to its hypnotic qualities. The 
dose is variously given as fifteen, forty, forty-five, 
and even sixty grains. 

Phenocoll, which is closely related to phenacetin, 
has been recommended both as an antipyretic and 
analgesic. In the latter capacity it has shown itself 
of special value in rheumatism, the pains of which 
often yield to it readily. 

It occurs as a crystalline powder of whitish color, 



196 PAIN. 

is soluble in water, and may be given several times 
a day, in doses of from ten to fifteen grains. 

Para-acetophenetidin, or "phenidin," is an anal- 
gesic of considerable value, being regarded by some 
as superior to antipyrin. It is closely related in its 
chemical structure to phenacetin, and may be given 
in doses of from ten to fifteen grains several times 
a day. 

Kapelline is an alkaloid derived from Aconitum 
napettus, and is said to be an analgesic of considera- 
ble value. I have not as yet had occasion to employ 
it. The remedy, which is soluble in water, has 
been given in doses of from one-fifth to one-half of 
a grain. 

Methylene blue, as its name sufficiently denotes, 
is a crystalline powder of bluish tinge, and has 
been considerably employed as an analgesic. It is 
soluble in diluted alcohol, but is best given in 
cachets or capsules, in doses of from two to six 
grains. 

Iodopyrin, as its name implies, is a chemical 
combination of antipyrin and iodine. It has been 
principally employed as an antipyretic and anal- 
gesic, but in the latter capacity it hardly equals 
antipyrin. 

On account of its insolubility the remedy is given 
in cachets, in doses of from two to ten grains. 



THE SPECIAL THERAPEUTICS OF PAIN. 197 

Methaeetine, or paraoxymethyl-acetanilid, is a rem- 
edy which of late has been commended as an anal- 
gesic and antiseptic. It is soluble in alcohol and 
chloroform, and may be given in cachets, in doses 
of from two to four grains. 

Local Analgesics. — Among the substances the 
local application of which (hypodermically) to pain- 
ful areas is capable of relieving pain by the induc- 
tion of insensibility in the part are cocaine and 
its various salts, methoxy-caffeine, kava-kava, and 
helleborein. 

Of these cocaine easily stands at the head, though 
the last-named substance, which is quite soluble in 
water, would be more valuable could it be employed 
more freely without danger of producing constitu- 
tional symptoms. 

Methoxy-caffeine may be given in doses of from 
three to four grains. 

Subsequently I shall detail at some length the 
various means to be employed in order to realize 
the fullest benefit from the use of these substances 
in the treatment of local pain. 



17* 



CHAPTER XIII. 

SUMMARY OF OTHER IMPORTANT FACTS RELATIVE TO THE 
ACTION OF REMEDIES ON THE NERVOUS SYSTEM. 

In the previous chapters have been enumerated 
some of the more conspicuous and important sub- 
stances used in the treatment of pain. It would be 
an error to suppose, however, that what has already 
been said is sufficient to enable us to proceed with- 
out further ceremony to the effective employment 
of these remedies. To appreciate this fact it must 
be borne in mind that substances introduced into 
the organism for remedial purposes are capable 
of being materially modified in their action by a 
variety of circumstances which concern both the 
individual acted upon and his environment. 

Let us consider for a moment some of the more 
important phenomena bearing on this question, and 
especially those which relate to the action of reme- 
dies on the central and peripheral nervous systems ; 
for it is with the latter that we shall be chiefly con- 
cerned in dealing with pain. 

The first and, indeed, the cardinal fact connected 
with the action of remedies upon the central nervous 
198 



THE SPECIAL THERAPEUTICS OF PAIN. 199 

system is that they exert their influence upon that 
system through the circulation ; for only so long as 
they remain dissolved in the blood are they con- 
veyed to the structures contained in the cerebro- 
spinal canal. Moreover, it follows that, as the 
heart's action is dependent upon nervous innerva- 
tion, it, too, can be modified only by remedies ac- 
tively circulating in the blood-stream. The truth 
of this proposition, being capable of easy demon- 
stration, is generally accepted, and needs, therefore, 
no further elucidation. But the fact, indisputable 
as it is, suggests this question : If remedies act 
through and by the circulation upon the cerebro- 
spinal nervous system, are changes in the blood- 
pressure followed by corresponding modifications 
in the physiological action of the remedy? The 
reply to this is that, at least in the case of some 
remedies, changes in the blood-pressure are indeed 
accompanied (followed) by commensurate variations 
in the physiological activity of the remedy. This 
applies with especial force to cerebro-spinal stimu- 
lants, and more particularly to those of an alcoholic 
and diffusible nature. It is applicable, moreover, 
to certain analgesics, notably antipyrin, and to some 
sedatives, — more especially the bromides. Hence 
it is that when the administration of these sub- 
stances is preceded by the exhibition of a cardiac 



200 PAIN. 

tonic a notable increase in effect is observed to 
follow. 

The same fact may, I believe, be invoked to ex- 
plain another interesting phenomenon. What I 
refer to is this, that differences in altitude of suffi- 
cient magnitude to cause marked variations in at- 
mospheric pressure are capable of modifying (in- 
creasing or decreasing) the physiological activity 
of drugs. That this is true has been attested again 
and again by travellers in the lofty regions of South 
America, where the atmospheric pressure is so re- 
duced as to cause the constitutional disturbances 
known collectively as " mountain fever." 

Inversely, it is a fact — which I was the first to 
show, as well as to make practical application of — 
that medicinal fluids, and more especially stimu- 
lants, are enhanced in their effects when exhibited 
while the subject remains in an atmosphere con- 
densed to a notable degree beyond the pressure of 
the normal atmosphere. 

To this conclusion I was inevitably compelled by 
a study of the habits of those persons who are 
obliged to labor in caissons and other devices em- 
ployed in laying the foundations of bridges and 
submarine tunnels. In a subsequent chapter, deal- 
ing with the practical application which I have 
made of this principle in neuro-therapeutics, the 



THE SPECIAL THERAPEUTICS OF PAIN. 201 

various matters at issue will be more thoroughly 
discussed ; for the present, however, let me say that 
in my opinion these effects of compressed air are 
due to the increased vaso-motor tension consequent 
upon the augmented action of the heart on the one 
hand, and the pressure of the blood from the sur- 
face towards the cerebro-spinal canal on the other. 
This increased activity of the heart and augmented 
vaso-motor pressure in the central nervous system 
are the direct sequences of the air compression at 
the surface of the body; and their combined result 
must be a material increase of exosmosis of medi- 
cated blood within the organs of the cerebro-spinal 
canal. Herein we find, I believe, the explanation 
of the increased physiological effect. 

The ability of heart tonics to augment the effects 
of certain stimulating, analgesic, and sedative sub- 
stances is doubtless explicable in the same way. 
Another principle of considerable theoretic and 
practical interest connected with the administration 
of remedies designed to affect the cerebro-spinal 
axis is that the longer a remedial substance, dis- 
solved in the blood, can be made to linger in con- 
tact with surrounding nervous structures the greater 
will be its physiological effect upon those struct- 
ures. This is the fundamental principle underlying 
the localization of remedies upon the central and 



202 pain. 

peripheral nervous system as elaborated and ex- 
pounded by the author. In a subsequent chapter 
the various technical details involved in its practical 
application will be more fully considered. 

Yet another fact of importance connected with 
the administration of cerebro-spinal remedies is, 
that not a few of them are materially modified, 
both in the intensity and duration of their action, 
by the degree of activity prevalent in the excretory 
organs, and more especially in the kidneys. When 
elimination proceeds rapidly the duration of the 
action of the remedy will be proportionably short- 
ened; whereas when there is present either renal 
disease or some other obstacle to excretion the drug 
accumulates in the system, and its physiological 
effects are necessarily prolonged. Moreover, it fol- 
lows that if the doses be too large or their exhibi- 
tion too frequent the accumulation may assume 
dangerous proportions. It is then that we are sud- 
denly confronted with the phenomenon of " cumu- 
lative" action, the significance of which, though 
often enough alluded to in the books, is but too 
frequently lost sight of. And yet to ignore the 
possibilities of danger implied by the process is to 
court fatality. This applies especially to the ad- 
ministration of many of the coal-tar derivatives 
previously described, substances which, though emi- 



THE SPECIAL THERAPEUTICS OF PAIN. 203 

nently useful in the management of pain, are at the 
same time burdened with the disadvantage that they 
exercise a decided depressant effect upon the heart 
when allowed to accumulate to an inordinate degree 
in the system. 

When called upon to give these remedies I am in 
the habit of safeguarding their administration in a 
twofold manner: first, by due examination of the 
kidneys, which enables one to determine whether 
there be grave disease, contraindicating the admin- 
istration of the remedy, or only a lethargy of action 
which may be adequately overcome by a diuretic ; 
and, secondly, by the previous exhibition of a heart 
tonic, even though there be no evidence of feeble 
action or organic disease. By the observance of 
these simple rules I have been able, I am sure, to 
ward off trouble on more than one occasion. 

There is hardly an analgesic or, indeed, for that 
matter, a remedy of real potency which is not capable 
of exercising some collateral ill effect on the organ- 
ism. Our aim should be to ferret out these asso- 
ciated disadvantages and to neutralize them as best 
we may by the simultaneous exhibition of correc- 
tives. This is self-evident. 

And yet there are those who are never weary of 
decrying the use of drugs on account of this con- 
comitant harmfulness, forgetting that if the logic 



204 pain. 

underlying such outlawry were really carried to its 
obvious sequences we should soon find ourselves 
bereft of practically all the really good things of 
internal therapy. 

Another point connected with the administration 
of cerebro-spinal remedies which is not always suffi- 
ciently appreciated is that old age is remarkably 
tolerant of stimulants, which seem, indeed, to afford 
substantial aid to the vital processes. This tolerance 
of stimulants is directly due to the relative obtuse- 
ness of the nervous system, which is so character- 
istic of the aged. Inversely, it is this very insensi- 
bility of the central nervous system in old persons 
which renders them intolerant of depressants, for 
these serve but to clog still further the already 
decrepit and irresponsive mechanism. 

A condition closely resembling this senile lethargy 
of the nervous system may be induced artificially, 
notably by the prolonged and immoderate use of 
alcohol. In persons who have suffered from such 
addiction narcotics, and especially stimulants, fail 
to act with their accustomed energy, and hence 
considerably increased doses are demanded in order 
to obtain even moderate effects. 

Herein lies the explanation, or, at least, the partial 
explanation, of the fact that the majority of patients 
encountered in public hospitals require much larger 



THE SPECIAL THEEAPEUTICS OF PAIN. 205 

doses than the refined persons met with in private 
practice. Destiny has decreed for the former class 
severe physical toil, with alternating excesses of a 
brutal character. The ultimate result of this low 
living is a distinct loss in nervous resiliency, and the 
consequent establishment of a condition of obtuse- 
ness as regards extraneous stimuli of all kinds. 
Quite the opposite condition is discernible in persons 
of refinement, for with them a sedentary and com- 
fortable mode of life — the exigencies of which are 
a constant appeal to the mental rather than the 
physical side of life — has culminated in the devel- 
opment of increased nervous irritability, of which 
marked susceptibility to drugs is but one of the 
modes of expression. Every practitioner of experi- 
ence will, I am sure, be able to recall many cases 
illustrative of this point. 

Finally, the various peculiarities of temperament 
and idiosyncrasy should all receive due considera- 
tion in determining the character of the remedies 
to be employed as well as their proper dosage. 

In the following pages an attempt will be made 
to apply in practice some of the principles enun- 
ciated in this chapter, and, notably, those pertaining 
to the localization of analgesics and the administra- 
tion of stimulants and sedatives under increased 
atmospheric pressure. 

18 



CHAPTER XIV. 

ON THE AUTHOR'S METHODS OF EMPLOYING REMEDIES SO 
AS TO INCREASE THE CERTAINTY AND DURATION OF THEIR 
ACTION ON THE PERIPHERAL NERVES— OTHER MEASURES 
WHICH HAVE BEEN PROPOSED. 

From what has been said regarding the conduc- 
tion of sensory impressions, it is evident that pain 
may be abolished in one of two ways: 1, by pre- 
venting the propagation of the morbidly intense 
impressions through the centripetal conducting 
paths (nerve and cord) to the sensorium ; and, 2, 
by so obtunding the perceptive mechanism that mor- 
bidly intense impressions, even when transmitted to 
the brain, are not felt to be painful. The first of 
these methods embraces all of those means which 
are applied to the nerve or cord with a view to pre- 
venting irritation, or at least interfering with its 
propagation to the brain. In this category belong 
the various chemicals, the surgical expedients, the 
counter-irritants, the thermic agents, and, in short, 
all therapeutic measures addressed to the nerve 
itself. To these must also be added all such means 

206 



THE SPECIAL THERAPEUTICS OF PAIN. 207 

as we are able to bring to bear upon the sensory 
conducting paths of the cord, for, as Erb long since 
observed, pain is seldom quite absent in diseases 
of the cord, though it may vary extremely in form 
and distribution. These pains are usually attribu- 
table to irritation of the posterior root-fibres, and 
their distribution will, of course, depend upon the 
extent to which the structures in question are impli- 
cated. 

The degree of permanency, and, consequently, 
the prognosis of such pains, will, however, depend 
upon the nature of the central lesion ; if the latter 
be due to the inflammatory condition present in the 
disease known as locomotor ataxia, or to pachymen- 
ingitis, the chances of permanent recovery are re- 
duced to a minimum ; whereas if passive congestion, 
as we find it, for example, in the caisson disease, be 
the cause of the central irritation, the prospect of 
getting rid of the pains is proportionately enhanced. 

Finally, under the head of the second method 
are included all appeals made to the receptive (per- 
ceptive) mechanism of the sensorium, in the form 
of opiates or other agents which tend to diminish 
acuity of sensory perception. 

1. The Application of Remedies to the Centrip- 
etal Conducting' Paths — Medication of the Nerves. 
— A large number of remedies may be applied to 



208 pain. 

affected nerve-filaments, either by the aid of the 
hypodermic syringe, endermically, or electro-chem- 
ically. Of the last-mentioned method I shall speak 
at once, not only because I was the first in this 
country to draw attention to its merits in connec- 
tion with the use of local analgesics in the treat- 
ment of pain, but because I have devised a procedure 
for carrying out the details of this form of medica- 
tion which I believe to be far more practical and 
effective than anything of the kind heretofore pro- 
posed. Before describing this method, however, let 
me observe that it is not my intention on the present 
occasion to enter into an extended discussion of the 
intricate pharmaco-dynamical questions involved in 
the treatment of pain. To do this would presuppose 
an intimate knowledge of the chemical constitution 
of nerve-tissue, — and such knowledge is at present 
denied us. While we cannot, therefore, know what 
chemical reactions are produced by the contact of a 
given medicament with the substance of a nerve, we 
may at least take cognizance of any considerable 
modification in the function of the latter thereby 
induced. 

Adopting this mode of reasoning, we find that 
with the remedies and methods available we are 
able to accomplish three things : we may tempo- 
rarily suspend the conduction in a nerve; or we 



THE SPECIAL THERAPEUTICS OF PAIN. 209 

may change its constitution sufficiently to allay 
irritation, and thus prevent the genesis of the ex- 
aggerated stimulus which gives rise to painful 
perceptions ; or, finally, we may destroy the morbid 
nerve-filaments altogether. The first result is best 
accomplished by the use of a local anaesthetic ; the 
second, by the subsequent application of chloro- 
form, ether, or similar agents, or by mechanical or 
thermodynamic aids; while the last is attained by 
the use of the knife. The first of these procedures 
is the one to which I give preference in cases of 
moderately acute pain, of unmistakably local char- 
acter ; the second finds its true field of application 
in those cases where it is desirable to produce a 
profound alterative effect upon the nerve; while 
the last, or surgical method, should be resorted to 
only in extreme cases, and after all other forms 
of treatment have failed to give relief. 

My first object, therefore, will be to show how 
remedies may best be introduced into the vicinity 
of affected nerves, and particularly those of the 
skin ; and how, when desirable, the action of me- 
dicinal substances upon the painful regions may be 
perpetuated. 

Introduction of Remedies into the Skin by the 
Aid of the Galvanic Current. — The procedure 
which I have found effective for the purpose is an 
o 18* 



210 PAIN. 

improvement on that first described by me in 1886. 1 
Its essential features are as follows : the region to 
be saturated with the chemical is first perforated 
by a large number of delicate needles, 2 which are^ 
driven into the part by releasing a spring, much 
after the plan of the old-fashioned spring lancet. 
The object of this manipulation is to increase the 
porosity of the skin, thus enabling the current to 
propel the chemical into the deeper tissues. As 
observed in the foot-note, however, it is of the 
utmost importance to employ only needles of the 
finest make, as, when larger ones are used, coarse 
openings are made, which no longer belong in the 
category of " pores," and through which the chemi- 
cal refuses to pass. On the other hand, the minute 
openings made with extremely fine needles are not 
visible to the naked eye, but are seen by the aid of 
a strong magnifying-glass as a collection of dots. 

1 New York Medical Journal, vol. xliv., November 19, 1886. 
See also Dr. David Webster, on " Coming's Method," Medical 
Kecord, March 5, 1887. Benjamin Kiehardson, of London, was 
one of the first to employ the galvanic current in conjunction with 
a chemical (chloroform) with a view to inducing local anaesthesia. 
This was long before cocaine was even heard of. 

2 This is nothing more than the instrument of the once famous 
charlatan Baunscheidt, supplied with unusually fine needles. The 
coarse instruments sold in the shops are of no value whatever, the 
needles being much too large. 



THE SPECIAL THERAPEUTICS OF PAIN. 211 

Having thus increased the porosity of the skin, 
it only remains to introduce the chemical into the 
tissues by the aid of the galvanic current. In order 
to accomplish this we proceed as follows : 

Two or three thicknesses of linen cloth are satu- 
rated with a five or six per cent, solution of the 
analgesic (cocaine), to which may be added, if con- 
sidered desirable, a few drops of the tincture of 
aconite. The linen cloth thus treated is then laid 
carefully over the perforated area of the skin, 
care being taken to avoid folds or other inequalities 
of its surface. A layer of potter's clay, of a con- 
sistency to be readily fashioned to any inequality of 
the body, is then spread over the linen cloth to the 
depth of about an inch. In this layer of clay we 
then imbed a thin sheet of copper or wire gauze. 
This clay electrode is then maintained in place by 
the aid of an elastic strap. 

The sheet of gauze or copper is then secured to 
the positive pole of an ordinary galvanic battery by 
means of the conducting cord, so that the current 
passes directly through the clay electrode and exer- 
cises its influence upon the analgesic contained in 
the cloth. 

As to the negative pole, I will merely state that 
it is to be placed as near as possible to the positive 
pole, but without touching it. A broad, flat sponge, 



212 PAIN. 

saturated with warm water, and held in place by an 
elastic strap, is quite sufficient. With regard to the 
strength of the current to be employed, much will 
depend upon the situation and extent of the terri- 
tory to be medicated. The greater the area to be 
aneesthetized the stronger and more protracted must 
be the application, always bearing in mind, how- 
ever, that treatment of the head and face must be 
conducted with caution, care being taken to avoid 
currents of too great strength. As for myself, I 
usually begin with three cells, gradually increasing 
their number until five or six are brought into 
requisition. When the application is made to other 
parts of the body, as, for example, to the extremi- 
ties, currents of very much greater strength may 
be employed. Currents of considerable quantity, 
such as those obtainable from large zinc and carbon 
cells, are preferable to all others. It is quite impos- 
sible to lay down infallible rules as to the length of 
time the current should be allowed to operate, since 
much must depend upon the strength of the battery 
and the extent of the territory which it is desired 
to medicate. From ten to twenty minutes are often 
quite sufficient, while under exceptional circum- 
stances it may even be advisable to let the current 
do its work for a longer time. In the majority of 
cases the pain will have left the part after the cur- 



THE SPECIAL THERAPEUTICS OF PAIN. 213 

rent has operated for eight or ten minutes. As a 
matter of course, should it be deemed advisable, 
supplementary injections of pyrogallic acid, theine, 
antipyrin, or other remedies may be made with a 
view to producing more pronounced and permanent 
effects upon the nerve. 

Again, it is often desirable to expose the affected 
nerve-filaments to the action of chemicals for a con- 
siderable length of time. This is not, however, to 
be attained by merely depositing the remedy in the 
vicinity of the nerve or its ramifications without 
farther precautions. In order to prolong the action 
of a remedy when thus injected we are obliged — as 
I long since pointed out — to resort to certain sup- 
plementary expedients. These I shall now proceed 
to describe. 

The Prolongation of the Local Action of the 
Remedy — Author's Methods. — When a remedy is 
injected into one of the extremities it is an easy 
matter to perpetuate its action to any reasonable 
extent. We have only, in fact, to suspend the action 
of the arterial and venous circulation, as I long 
since demonstrated, 1 by the aid of an appropriate 

1 " On the Prolongation of the Anaesthetic Effects of the Hydro- 
chlorate of Cocaine when Subcutaneously Injected : an Experi- 
mental Study," New York Medical Journal, September 19, 1885; 
" Prolonged Local Anesthetization by Incarceration," ibid., Janu- 



214 



PAIN. 



bandage. By this simple means we are enabled to 
keep the remedy for a certain length of time in 
contact with the nerve-filaments; for, the circula- 
tion in the part being suspended, the blood cannot 
dissipate it (the remedy) throughout the organism. 
Likewise, about the breast and back, we can accom- 
plish the same thing, though in a much less perfect 
manner, by resorting to compression by the aid of 
rings, clamps, and the like. When, however, we 
desire to perpetuate more completely the action of 
the drug in the dorsal or thoracic region, the 
problem is wholly different, since rings and similar 
devices are not adequate. To meet this difficulty 
I have devised the following procedure : * 

Having introduced the remedy throughout the 

ary 2, 1886 ; " Spinal Anaesthesia and Local Medication of the 
Cord," ibid., October 31, 1885; "Local Anaesthesia," New York, 
D. Appleton & Co., 1886. See also Wyeth, John A., on " Com- 
ing's Method of inducing Cocaine Anaesthesia," " A Text-Book 
on Surgery," New York, 1887, p. 22; also Smith, Stephen, on 
Coming's method, " Principles and Practice of Surgery," Philadel- 
phia, 1887, p. 54 et seq. See other communications on the subject 
by J. K. Conway, J. Williston Wright, Eobert F. "Weir, M. J. 
Koberts, and others. 

1 " The Medication of Nerves, and its Application in the Treatment 
of Neuralgia and other Painful Affections," a paper read before the 
Medical Society of the State of New York, February 1, 1887, pub- 
lished in the Medical Kecord for March 19, 1887. 



THE SPECIAL THERAPEUTICS OF PAIN. 215 

painful territory, according to the method previ- 
ously described, I place over the part a piece of fine 
wire gauze, which is trimmed with a pair of scissors 
so as exactly to cover the medicated zone. A 
T-shaped block of wood (Fig. 5) is then placed upon 
the wire gauze, and a considerable degree of press- 
ure applied, by means of an elastic strap which encir- 
cles the body and is secured in place by means of a 
buckle. The same thing may ~ g 

be accomplished by placing 
a heavy lead weight upon the 
wire gauze while the patient 
remains in a recumbent posi- 
tion. As a result of this the 
gauze is pressed well into the 
skin, and the septa of the same 
cause occlusion of the subjacent capillaries, but with- 
out pressing out the remedy, which remains caught, 
as it were, in the meshes. By this method I have 
often produced a state of complete anaesthesia (by 
the use of cocaine alone or with antipyrin) lasting an 
hour and a half. It is not surprising, therefore, that 
such a protracted exposure of the nerve-filaments to 
the influence of chemicals should often result in per- 
manent abolition of the painful sensations. Where 
the pain is located above the eyes, as in supraorbital 
neuralgia, or in the temple, this mode of treatment 




216 PAIN. 

often acts like magic ; but let me add that cocaine 
alone is by no means always adequate to secure this 
end; its function is rather to render the painless 
employment of other remedies possible. 

Sometimes, in uncomplicated cases, one applica- 
tion is sufficient to abolish the pain for weeks or 
even months. In others, again, the pain may return 
after a few days, but with less intensity. In any 
event, constitutional treatment should always be 
continued side by side with local measures, so that 
septic or other conditions which incite or favor the 
development of neuritis may be removed. 

Therapeutic Thrombosis, or the Localization and 
Prolongation of the Action of Analgesics and other 
Remedies without Mechanical Aids. — It is obvious 
that the mechanical aids previously described are 
not equally applicable in all parts of the body ; and 
hence it would be a great advantage if one could 
attain the same end — localization of the remedy — 
in some other way. Appreciating this fact, I ad- 
dressed my efforts, some time since, to the problem 
of dispensing with them altogether; and in the 
New York Medical Journal of December 26, 1891, 
vol. liv., I have given an account of these re- 
searches. 

Let me describe this method of perpetuating the 
action of remedies, and more especially local anal- 



THE SPECIAL THERAPEUTICS OF PAIN. 217 

gesics and anaesthetics ; and, to facilitate the recital, 
let it be assumed that we wish to perpetuate the 
action of an anaesthetic upon the cutaneous nerves. 

In the first place, four principles are embodied in 
the procedure ; these are : 

1. Injection of the medicinal solution (anaesthetic) 
into the skin. 

2. Subsequent introduction through the same hy- 
podermic needle, and without its removal from the 
part, of a non-irritant oil. 

3. Precipitation of this oil, after its injection into 
the skin, by the aid of moderate cold, but without 
freezing the tissues. 

4. Taking up the slack of the skin near the seat 
of injection. 

The technique involved in the practical applica- 
tion of these principles may be thus described : 

In the first place, we inject an aqueous solution 
of the anaesthetic, cocaine (C 17 H 21 N0 4 , HC1), into 
that portion of the skin which we desire to render 
insensible. Then, without removing the hypodermic 
needle, we immediately inject a considerable quan- 
tity of the oil of theobroma, or cacao butter, as it is 
commonly called. 

Finally, by the application of cold to the skin 
directly after the execution of these manoeuvres, we 
cause the oil to solidify within the parenchyma, 

K 19 



218 



PAIN. 



thus obstructing the circulation in the capillaries 
and causing more or less complete stasis. 

To carry these manipulations into effect a double 
syringe is required, one barrel containing a two or 
three per cent, solution of the hydrochlorate of 
cocaine and the other the oil of theobroma, which 
is maintained in a fluid state by occasionally dip- 
ping the syringe into warm water of about 110° F. 



Fig. 6. 




The capacity of the barrel containing the anaes- 
thetic is one hundred minims, while that destined 
for the oil will readily hold four or five hundred 
minims. 

Both of these barrels are connected by means of 
a bifurcated tube with the same needle; so that, 
by pressing first upon one piston-rod and then 
upon the other, the two liquids may be injected 
alternately through the needle at the will of the 
operator (Fig. 6). 

I wish to acknowledge the carefulness with which 



THE SPECIAL THERAPEUTICS OF PAIN. 219 

Mr. "W. F. Ford, the instrument-maker, has fol- 
lowed my instructions in making the syringe. 

It is absolutely necessary that both the aqueous 
solution of the anaesthetic and the oil should pro- 
ceed along the same path, so that the occlusion of 
the capillaries shall occur immediately after anes- 
thetization of the sensory filaments in their im- 
mediate vicinity. Hence the necessity of employing 
a double syringe and an aqueous solution of the 
anaesthetic, — a solution that does not combine or 
solidify with the oil of theobroma, but remains fluid, 
and therefore physiologically potent, about the fila- 
ments of the sensory nerves. It is evident that 
oleaginous solutions of the alkaloid (cocaine) are 
inapplicable, for the simple reason that they com- 
bine and then solidify with the oil of theobroma, 
and are thus rendered inoperative, as is shown by 
the immediate disappearance of the anaesthesia. 

The precipitation (solidification) of the oil in the 
tissues may be accomplished by the application to 
the skin of either cold water, ice, or the ether spray. 
I prefer the latter expedient. It is by no means 
necessary to spray the parts continuously, occasional 
refrigeration being all that is required to maintain 
the oil in a solid state within the tissues. To ap- 
preciate this point, it must be borne in mind that 
the melting-point of the oil of theobroma is from 



220 pain. 

86° to 95° F., so that a reduction in temperature of 
from 15° to 20° is sufficient to keep the oil in a solid 
state within the parenchyma. Moreover, the oil 
of theobroma is specially applicable on account of 
its bland, non-irritating properties, which admit of 
its injection in large quantities without the least 
chance of unpleasant consequences. 

As a matter of course, having served its purpose, 
the oil is melted and deported by the general circu- 
lation when the application of cold to the skin is 
discontinued. 

But even during the application of cold there is 
a gradual melting of the solidified oil, beginning at 
the periphery and proceeding towards the centre. 
In consequence of this the anaesthesia tends also 
to disappear at the periphery. 

This subsidence of the anaesthesia may be enor- 
mously retarded by simply taking up the slack of 
the skin outside the zone of anaesthesia. To accom- 
plish this it is only necessary to make a fold in the 
skin and maintain the latter by means of a strip or 
two of ordinary elastic adhesive plaster or by the 
application of a small spring clothes-pin, which may 
be had in the shops for a few cents. It must not, 
however, be inferred that stretching the skin is 
requisite to the attainment of the most complete 
results ; all that is required is the elimination of the 



THE SPECIAL THERAPEUTICS OF PAIN. 221 

excessive elasticity of the skin at the seat of injection. 
When this is done in the simple manner previously 
described the tissues above the solidified fatty mass 
— and nowhere else — retain a milky-white appear- 
ance as long as the oil is maintained in a compact 
condition by the judicious application of cold. As 
soon, however, as the fatty mass is allowed to melt, 
or, in other words, when we neglect to spray the 
injected area with ether from time to time, the skin 
resumes its normal appearance and the anaesthesia 
is at an end. Here we have the absolute demon- 
stration of the efficacy of the hardened oil to prac- 
tically arrest the capillary circulation at the seat of 
injection. 

By the application of these principles I have suc- 
ceeded in maintaining a limited zone of anaesthesia 
for considerably over an hour, and I see no reason 
why the anaesthesia should not be maintained for 
two hours or more. 

I fancy that, to the practical members of the 
profession, this procedure will speak for itself, and 
I shall therefore refrain from commenting further 
upon it. 

The expedients heretofore discussed are such as 
have reference to the treatment of pain when due 
to implication of the superficially-located nerves, 
and, notably, those of the skin. But pain is by no 

19* 



222 pain. 

means always due to implication of these nerve- 
branches; on the contrary, it is often traceable to 
changes in or about the trunk itself, which may be 
profoundly located, as in the case of the sciatic 
nerve. How to deal effectively with pain when 
originating in this Way is one of the interesting 
problems of medicine. 

As for myself, I have striven to meet the indica- 
tions in a variety of ways. Sometimes I have in- 
jected chemicals, such as pyrogallic acid, cocaine, 
and aconite, down to the nerve by the aid of a long, 
fine needle and syringe. Then, in order to insure 
a more complete exposure of the affected nerve- 
tissue to the influence of the chemicals, I have 
passed a tourniquet around the limb, above the 
point of injection, securing it with sufficient tight- 
ness to shut off the circulation in both artery and 
vein. The obvious effect of this is to prevent the 
deportation of the injected chemicals into the gen- 
eral circulation; consequently, they linger about 
the nerve, and are able to do their work as long as 
the tourniquet remains in place. 

To render the pressure of the tourniquet bearable, 
however, it is imperatively necessary, before apply- 
ing it, to exsanguinate the limb with an Esmarch 
bandage. 

Several years ago I published some cases illus- 



THE SPECIAL THERAPEUTICS OF PAIN. 



223 



Fig. 7. 



trating the favorable results which are sometimes 
attainable by this plan of treatment. 

In addition to the measures previously described 
a large number of other expedients have been re- 
sorted to in the treatment of pain. Prominent 
among these is electricity, which in the form of the 
galvanic, and more especially the induced (Faradic), 
current has been extensively employed. Within 
a short time, too, a 
great improvement 
has been made in the 
construction of the 
Faradic battery, and, 
notably, in the vibra- 
tor or rheotome, by 
means of which an 
enormous number of 
interruptions is se- 
cured, thereby en- 
hancing to a material 
extent the analgesic 
properties of the cur- 
rent. By far the best battery of this kind is that 
suggested by Dr. Augustin B". Goelet (Fig. 7); it 
is constructed in a most elegant manner by the 
Galvano-Faradic Manufacturing Company, of New 
York. 




224 pain. 

It has long been known that pressure applied to 
the stem or larger branches of a nerve is often in- 
strumental in arresting pain. But the procedure is 
much more effective when combined with the use 
of the Faradic current, as was pointed out by the 
author several years ago. 

To carry out this combined treatment I have had 
made for me an electrode provided with a stout 
leather band to encircle the limb. This band is 

pierced by a screw, by the 
rotation of which the press- 
ure may be increased or 
decreased at will. A bind- 
ing post at the top of this 
screw serves to attach the 
conducting cord, which 
unites the electrode with 
one of the poles of a 
Faradic battery (Fig. 8). The pad of this elec- 
trode is covered with chamois-skin, which should 
be thoroughly moistened before applying it to the 
part. As a rule, the electro-pressure should be 
applied centrally, — i.e., as high up as possible; 
whereas the electrode designed to complete the 
circuit should be located at the periphery. Thus, 
in treating sciatica, the foot of the patient may be 
allowed to rest on a metal electrode, while the 




THE SPECIAL THERAPEUTICS OF PAIN. 225 

pressure-electrode is placed over the nerve, as near 
its point of exit from the pelvis as possible. 

The application of cold to the painful area is an 
old expedient. The usual mode of accomplishing 
it is by projecting an ether spray upon the part, as 
suggested by Sir Benjamin Richardson. Packing 
the whole limb with ice has also been resorted to, 
notably in the treatment of sciatica. 

Heat has been even more extensively employed 
than cold in the treatment of pain, either in the 
form of cloths saturated with hot water and re- 
newed at frequent intervals; or by means of hot 
plates of metal enveloped in flannel ; or by the aid 
of rubber bags filled with hot water, as suggested 
by Dr. Chapman. When applied to the spine in 
this way some effect upon the central nervous 
system is doubtless produced; but the miraculous 
phenomena described by Chapman and some of 
his followers are, in my experience, not forth- 
coming. But, while this indirect method is of 
relatively restricted utility, it is a matter of com- 
mon professional experience that the direct appli- 
cation of heat to the seat of pain is often, though 
certainly not invariably, productive of relief. 

Counter-irritation, either in the form of blisters or 
acupuncture, has been extensively resorted to from 
a remote period. In the last-named form it has 
p 



226 pain. 

been employed in China for centuries, special vir- 
tues being ascribed to the long needles of gold and 
silver, which are thrust, it is said, without hesitancy 
into almost all the accessible regions of the body. 
Such empirical procedures have, however, hardly 
more than an historical value, being manifestly in- 
ferior to modern scientific methods. 

Ointments of various kinds have long been em- 
ployed in the treatment of pain. 

The remedies best suited to be applied in the 
form of salves in neuralgic affections are veratrine, 
morphine, belladonna, aconitia, and extract of 
opium. 

Aconitia (one part to thirty) should be rubbed 
into the painful areas until numbness is induced. 

Veratrine (one part to twenty-five) may be ap- 
plied twice or thrice daily, care being taken to con- 
tinue the friction until pricking sensations are 
experienced. Erb recommends one part of bella- 
donna, four parts of glycerin, and four parts of 
starch, the ointment to be applied on a compress or 
rubbed into the painful cutaneous districts. 



CHAPTER XV. 

SURGICAL EXPEDIENTS. 

As is well known to every medical man of ex- 
tensive experience, cases of pain are occasionally met 
with which we are not able to relieve, much less 
to cure permanently. In such desperate cases as 
these it is customary, as a last resort, to invoke 
the assistance of surgery. 

The two procedures commonly employed are 
neurotomy and neurectomy. The first operation 
consists in simple division of the nerve above the 
point of irritation ; while the second is a more radi- 
cal procedure, involving resection of a portion of 
the affected nerve. 

Both of these operations are, of course, under- 
taken with a view to preventing the propagation of 
the painful sensations to the brain. 

Interference with the circulation in a painful 
region has been known to abolish permanently all 
unpleasant symptoms in the part. 

This observation has led surgeons to ligate the 
arteries supplying the painful area. Thus, Trousseau 

227 



228 pain. 

frequently divided and subsequently ligated the 
temporal and occipital arteries in neuralgia of the 
head; and the results thus obtained were some- 
times quite remarkable. 

Guided by a similar train of reflections, Nuss- 
baum, of Germany, ligated the carotid artery in 
a desperate case of neuralgia of the face, with the 
happiest results, the cure effected being to all intents 
and purposes complete. 

Inveterate cases of tic douloureux are, fortunately, 
not so very common; but when they occur, the 
misery which accompanies them is inexpressible. 
Until 1851, when Dr. J. M. Carnochan operated by 
completely resecting the second branch of the fifth 
nerve, we were in a state of more or less helpless- 
ness when confronted by one of these old cases 
of tic. 

Dr. Carnochan's mode of operating is thus de- 
scribed by Dr. Tvobert Abbe, 1 who has improved it 
in some important particulars : " A V incision was 
first made below the eye, and from its apex a 
straight cut was extended downwards through the 
entire cheek and lip half-way between the nose and 
the corner of the mouth. The nerve ends were 

1 " The Surgical Treatment of Inveterate Tic Douloureux," by 
Kobert Abbe, M.D., the New York Medical Journal for August 3, 
1889. 



THE SPECIAL THERAPEUTICS OF PAIN. 229 

then gathered up at the foramen of exit, and a 
trephine was applied to the front of the jaw, re- 
moving the front bony wall of the antrum. The 
roof of this cavity, being of thin bone, is readily 
broken in, and the nerve drawn down from the 
orbital cavity. The back of the antrum is next 
broken away and removed, which exposes the 
spheno-maxillary fossa, which at this point is little 
more than half an inch deep. The nerve can now 
be cleaned away from its cellular surroundings and 
traced to the foramen rotundum, which is on a line 
with the inner wall of the antrum. Here it is 
readily cut square off. The posterior dental nerves 
and Meckel's ganglion connect in front of this, 
and thus all communication of the jaw with the 
nerve-centres is cut off beyond the chance of re- 
pair." 

Dr. James R. Wood employed Carnochan's method 
of operating in a number of cases, and modified it 
only to the extent of abbreviating the incision, so 
as not to carry it clear through the lip. 

Dr. Abbe has adopted some changes of technique 
which clearly enhance the value of the operation ; 
for he observes, " the simplifying of dressings and 
attainment of primary union in the wounds now 
possible make certain valuable modifications of the 
operation practical." 

20 



230 pain. 

" I have adopted these expedients," he continues, 
" in three cases. 

" The best point is the small skin incision, which 
leaves a small scar. One inch and a quarter, either 
horizontally, vertically, or obliquely, over the infra- 
orbital foramen gives ample room for operating. 
I have found a gouge better than a trephine for 
penetrating the antrum front and back. A narrow, 
forked, blunt instrument to straddle the nerve and 
assist in dragging it down into the antrum saves it 
from laceration. 

" Eo bleeding occurs that is not readily checked 
by sponge-pressure, even the sharp welling-up that 
occurs when the nerve and its companion vessel are 
cut. The dressing of the wound is of special im- 
portance, and the most perfect result is obtained by 
packing iodoform gauze tightly into the antrum, 
the end of a long strip being folded into a small 
pad to be placed deep in the wound against the 
foramen rotundum, and the rest lightly added on 
top, and allowed to keep the wound apart on the 
cheek. After thirty-six or forty-eight hours this 
gauze is entirely removed and the wound sutured 
with care. 

" The anaesthesia of the cheek allows of secondary 
suturing without pain to the patient. What little 
exudation may follow this dressing is retained and 



THE SPECIAL THERAPEUTICS OF PAIN. 231 

needs no drainage, primary union invariably result- 
ing if the dressing is made with care. The de- 
pressed scar becomes flattened after a few weeks." 

The histories of the three cases operated upon by 
Dr. Abbe may be found in the paper from which 
the above extracts are taken. 

I will finally observe in this connection that 
Dr. Frederic S. Dennis, 1 of New York, collected 
twenty-one cases of this operation several years 
since, an analysis of which affords ample proof of 
the merits of this surgical expedient. A perusal 
of Dr. Dennis's admirable paper will be found 
alike interesting and instructive. 

It is much to be regretted that in a large number 
of painful conditions, owing to the fact that so many 
nerve-trunks contain both sensory and motor fibres, 
division of the nerve cannot be resorted to without 
the simultaneous induction of paralysis of motion. 

Division of the Sensory Nerve-Roots for Invet- 
erate Pain. — Attention has just been drawn to the 
fact that the majority of those nerves most liable 
to become the seat of neuritis contain both motor 
and sensory fibres. Hence division of such nerves 
with the knife, for the permanent relief of severe 
and chronic pain, is not usually justifiable, for the 

1 The New York Medical Journal for June, 1879. 



232 pain. 

simple reason that the operation not only destroys 
the sensibility in the part but (what is much more 
deplorable) it also induces paralysis. In order to 
avoid causing such paralysis of the muscles it has 
been proposed to divide the posterior nerve-roots, 
from which the sensory filaments of the affected 
nerves are derived. To do this successfully involves 
a knowledge of what nerve-roots go to make up 
the various plexuses and nerves most liable to be 
attacked by severe neuritis. Thus, if we are con- 
fronted with an inveterate brachial neuralgia which 
has resisted all forms of medical treatment, the ques- 
tion of an operation may imperatively suggest itself 
to the mind of the patient or his friends. Under 
such circumstances, rather than reduce the arm to 
a state of helplessness by cutting or resecting the 
nerves, we may divide some or all of the posterior 
nerve-roots which contribute sensory filaments to 
the affected nerve or plexus, whereby sensation is 
lost but motility retained. All this has quite a 
plausible ring; but the practical realization is not 
always correspondingly satisfactory. There are two 
reasons for this. In the first place, as every physi- 
cian is aware, it is not always easy to determine with 
absolute certainty just how many branches of a 
plexus (or nerve) are actually implicated in a given 
case of neuralgia, since some of the pains may be 



THE SPECIAL THERAPEUTICS OF PAIX. 233 

"reflected;" and, secondly, if the simple nerve 
relations be often difficult to decide upon, how 
much more intricate must be the question as to 
the exact number of sensory nerve-roots which 
must be divided in order to obtain the maximum 
relief with the minimum of anaesthesia ! No ana- 
tomical statistics, however well tabulated, afford an 
infallible key to the situation. Nor is any one to 
blame for this, since, as has just been shown, the 
complications are inherent and not readily amenable 
to simple a priori solution. Dispensing with theo- 
retic refinements, we must make up our minds, 
then, to produce anaesthesia so extensive as to abso- 
lutely insure the abolition of the pain. This we 
may accomplish by dividing at once a sufficient 
number of posterior nerve-roots to rob the plexus 
of its sensory functions. The remedy is drastic, 
but vastly to be preferred to the ruthless expedient 
of division of the nerve itself with the attendant 
motor paralysis. 

Removal of the Semilunar Gang-lion for Ob- 
stinate Facial Neuralgia, as Practised by Rose and 
Andrews. — It would be a manifest omission were 
we to neglect to give a description of the radical and 
comparatively new operation of excision of the semi- 
lunar ganglion for intractable trigeminal neuralgia, 
as first practised by Dr. Rose, of London. An 

20* 



234 pain. 

exceedingly lucid and instructive account of this 
operation has been given by Dr. Edmund Andrews, 
of Chicago, who has already removed the ganglion 
several times. 

The following description with diagrams illus- 
trating the technical points involved are taken from 
Dr. Andrews's admirable paper. 1 I desire also to 
express my acknowledgments to Messrs. Lippincott 
Company for kindly furnishing me the electrotypes 
from which these illustrations are made. 

" The first operation of Rose was modified by the 
demands of the patient, who insisted that he should 
remove the superior maxilla, where he felt the 
principal pain. Professor Rose, in this instance, 
therefore, consented to remove that bone. This 
uncovered the fossa behind it, thus gaining an easy 
access to the foramen ovale, from which the inferior 
maxillary nerve emerges. Placing the centre-pin 
of a trephine in the foramen, he took out a half- 
inch disk surrounding the orifice; then, opening 
the capsule of the ganglion, he divided the superior 
maxillary branch, and, with some difficulty, picked 
out and removed almost all of the ganglion. This 

1 " Two Cases of the Eemoval of the Semilunar Ganglion through 
the Floor of the Skull for Facial Neuralgia," by Edmund An- 
drews, M.D., etc., International Medical Magazine, vol. i., No. 5, 
June, 1892, p. 479 et seq. 



THE SPECIAL THEEAPEUTICS OF PAIN. 



235 



was twenty- two months ago, and the patient still 
remains free from pain. In his second and third 
operations, Eose avoided the removal of the superior 

Fig. 9. 




Rose's first operation, with the long, blunt centre-pin of the trephine 
inserted into the foramen ovale. S, S, S, the floor and side of the cranium ; 
0, the Gasserian ganglion ; F, the foramen ovale ; T, the trephine ; D, the 
dura mater ; C, the carotid artery ; J, the lower jaw. 



maxillary bone by uncovering the parts from the 
side of the face, as is shown in Fig. 12. In his 
fourth and fifth operations, he proceeded in essen- 
tially the same way, but on reaching the floor of 



236 pain. 

the cranium he selected the place for the applica- 
tion of the trephine, which I had previously urged 
before the American Medical Association, — that is, 
not directly upon the foramen ovale, but just ex- 
ternal to it, as shown in Figs. 10 and 11. In a 
letter to me, Professor Rose gives the opinion that 
the new place of opening the skull is preferable to 
the former one. 

" The anatomy of the parts is briefly this : The 
fifth nerve emerges from the medulla oblongata in 
a flat, soft trunk, which is easily torn, and is very 
different in structure from the divisions issuing 
from the distal side of the ganglion to supply the 
facial organs. Passing forward over the crest of 
the petrous portion of the temporal bone, it enters 
a small opening in the dura mater, and expands 
into the semilunar ganglion on the anterior slope 
of the petrous portion of the temporal bone. The 
dura mater here divides into two layers, enclosing 
the ganglion in a sort of capsule ; the upper layer 
is thick and strong, and the ganglion is firmly ad- 
herent to it. The lower layer, next to the bone, is 
very thin and delicate, and the ganglion easily sepa- 
rates from it. The ophthalmic, with the superior 
and inferior maxillary trunks, is given off from the 
anterior edge of the ganglion to proceed to the face. 
The largest of these divisions is the inferior maxil- 



THE SPECIAL THERAPEUTICS OF PAIN. 237 

lary, which emerges from the skull through the 
foramen ovale as a somewhat thick cord, very firmly 
invested with a prolongation of the dura mater, so 
that it is strong and will withstand a good deal of 
tension without breaking. Soon after leaving the 
foramen it divides into two branches, — the inferior 
dental, which enters the canal in the inferior maxilla 
and supplies the teeth, lower lip, etc., and the gusta- 
tory nerve, running to the side of the tongue. The 
direction of the parts is such that a probe carried 
along the trunk of the inferior dental nerve, from 
its point of entrance into the ramus of the jaw, 
upward and inward to the foramen ovale, passes 
through the foramen straight onward into the centre 
of the semilunar ganglion. Fig. 9 shows this rela- 
tion, with the trephine applied with its centre-pin 
in the foramen, according to Rose's first and second 
operations. Fig. 10 shows the same general rela- 
tions with the trephine applied to the surface, just 
external to the foramen ovale, and advocated by me 
as the best point before Professor Rose adopted it, 
though the latter's selection of it was the result of 
his own investigations without communication with 
me. Fig. 11 shows the relation of the parts at the 
base of the skull ; F is the foramen ovale, which 
gives exit to the inferior maxillary nerve; F S is 
the foramen spinosum, through which the middle 



238 



PAIN. 



meningeal artery enters the skull; E P is the ex- 
ternal pterygoid plate, whose free external edge 
runs directly to the anterior extremity of the 



Fig. 10. 



Fig. 11. 




A, the cranium; G, the ganglion; X, 
the carotid artery ; S, the sphenoidal sinus ; 
D, the dental branch of the nerve ; T, the 
gustatory branch, natural size. 



Shows the relation of the 
parts at the base of the skull. 
For description see text. 



foramen ovale, but is sometimes prolonged by a 
ridge on the inner side, and sometimes on the outer 
side, but always close to it ; hence it is an important 
landmark for finding the foramen ; P is the ptery- 



THE SPECIAL THERAPEUTICS OF PAIN. 239 

goid ridge, sometimes also an important landmark. 
The black circle on the drawing, just external to 

Fig. 12. 




Rose's second operation. Z, lower flap, containing zygomatic arch; T, 
upper flap, carrying up the coronoid process ; P, external pterygoid muscle ; 
A, superior maxillary artery ; N, the gustatory and inferior dental nerves. 
Their course behind the pterygoid muscles is indicated by dotted lines. 
The foramen ovale is just back of P. 

the foramen ovale, shows the place for applying the 
trephine." 

In concluding his most instructive paper Dr. 
Andrews observes that " of the seven cases done 



240 pain. 

by Professor Rose and myself no one has shown 
any dangerous symptoms, and not one has failed to 
obtain perfect relief from the pain. The operation 
is so utterly new in its present form that there has 
been no time to decide by experience on the perma- 
nency of the cures, but, as I before remarked, there 
is reason for hoping that in the majority of instances 
the disease has not extended beyond the semilunar 
ganglion, and, hence, the operation of removing the 
whole of it may be expected to be followed by 
permanent relief." 



CHAPTER XVI. 

LOCAL MEDICATION OF THE SPINAL CORD. 

I have already referred to the frequency with 
which pain is associated with affections of the spinal 
cord, and I now desire to offer some suggestions 
regarding the most practical means to be adopted 
in the management of this troublesome symptom. 

Let me preface the specific rules to be observed 
in treatment by a retrospective glance at the argu- 
ment upon which those maxims are based. 

To begin with my first paper on the subject of 
direct cord medication, I may state that as long ago 
as 1885 1 I showed that when a given amount of 
chemical substance, in aqueous or oleaginous solu- 
tion, is injected into the vicinity of the spinal cord 
certain modifications in the functions of the latter 
may be induced. 

Thus, when strychnine is injected in this manner, 
the functions of the cord, and, notably, the reflexes, 
are greatly exalted ; much more so, in fact, than if 
the medicament had been simply injected into the 

1 The New York Medical Journal for October 31, 1885. 
l q 21 241 



242 pain. 

general circulation, as in ordinary hypodermic med- 
ication. On the other hand, the modifications in 
function which I have observed after injection of an 
anaesthetic, such as cocaine, were sensory in charac- 
ter, — such, for example, as more or less complete 
anaesthesia, tingling, numbness, and various other 
parsesthesiae, these phenomena being principally re- 
stricted to the lower limbs, scrotum, and other 
parts below the point of injection. The line of 
argument which led up to these results it is not 
necessary to detail on the present occasion ; enough 
that the whole chain of experimental proof then 
and afterwards adduced 1 was amply verified in the 
clinic. 

So convinced have I become of the necessity of 
making some radical improvement in our methods 
of dealing with pain originating in difficulties of 
the cord that, when I observed how vastly more 
potent are the effects of remedies when brought 
directly in contact with the cord than when intro- 
duced into the system in a merely general way, I 
determined to perfect the technique of making 
local applications to the organ, so as to place the 
procedure on a sound basis. 



1 " Further Contribution on Local Medication of the Spinal Cord, 
with Cases," the Medical Kecord for March 17, 1888. 



THE SPECIAL THEEAPEUTICS OF PAIN. 243 

There was one obstacle in particular to be over- 
come in order to accomplish the practical ends 
of the undertaking. 

Briefly stated, the problem in question is this : 
How is the physician to know how far he may 
thrust the hollow needle, used in transmitting the 
medicament from the syringe to the vicinity of the 
cord, without danger of wounding the latter ? 

As I have said, this problem puzzled me for a 
time ; and yet there was no evading it, for I saw at 
once that if the procedure were to prove effective 
it could only do so by enabling one to deposit the 
medicinal solution close to the cord. This is how 
the matter was at length accomplished. Having 
examined the vertebrae of the lower portion of the 
spinal column, I observed that the posterior surface 
of the transverse process, even at its greatest de- 
pression, though almost on a level with the pos- 
terior aspect of the foramen vertebrae, did not fall 
at all, or, in rare cases, possibly very slightly below 
it. This is especially true of the ninth, tenth, 
eleventh, and twelfth dorsal and of the first and 
second lumbar vertebrae. As soon as I had ob- 
served this anatomical coincidence, I saw at once 
that, in so far as the lower vertebrae were concerned, 
the problem of approaching the immediate vicinity 
of the cord with the point of a hypodermic needle, 



244 pain. 

without danger of wounding it, was solved. In 
a word, to make the matter short, the simple 
technique which I elaborated on the basis of these 
observations is as follows : 

1. I first, as a rule, induce a condition of cuta- 
neous anaesthesia in the vicinity of the spinous 
processes of the tenth and eleventh dorsal vertebrae 
almost as large as a silver dollar. This I do simply 
for the comfort of the patient, and for no other 

Fig. 13. 



purpose. The electro-chemical method T previously 
described or refrigeration with the ether spray may 
be invoked for the purpose. 

2. I now call into requisition a fine needle, about 
three inches long, provided with a handle and a 
sliding nut (Fig. 13). The latter may be fixed at 
any portion of the continuity of the needle by 
means of the screw. This needle I thrust down 
(about half an inch laterally from the spinous 
process of the tenth dorsal vertebra) until the bone 
is reached (Fig. 14). The nut is then pushed down 
till it rests lightly upon the skin, and is secured in 

1 See the New York Medical Journal for November 6, 1886. 



THE SPECIAL THERAPEUTICS OF PAIN. 



245 



place by means of the screw. I then withdraw the 
needle. 

It is now clear, from what has already been said, 
that the space between the nut and the point of the 



Fig. 14. 







needle corresponds almost exactly with the distance 
from the surface of the integument to the cord. 
To make assurance doubly sure, however, I am in 

21* 



246 pain. 

the habit of subtracting two or three millimetres 
from the measurement thus attained. 

3. Upon a fine canula (Fig. 15), likewise provided 
with a sliding nut, the distance previously noted 
upon the needle is measured off (minus two or three 
millimetres), and the nut secured firmly in place. 

This hollow needle is then attached to a syringe 
(Fig. 16) of one hundred minims capacity, filled 

Fig. 15. 




with a one and a half per cent, solution of the 
anaesthetic (cocaine); antipyrin or methoxy caffeine 
may also be employed in the same way. 

So much, then, for the technique of this mode of 
treatment. Relatively long as is necessarily the 
description, the execution of the manipulations 
themselves is by no means so difficult as might be 
imagined. I have employed the procedure many 
times, sometimes using cocaine alone, and sometimes 
combined with the tincture of aconite or pyrogallic 
acid, antipyrin, methoxy caffeine, or strychnine. 

In the affection commonly known as spinal irrita- 
tion — whether there be a condition of congestion or 
anaemia, I care not — its effects are certainly in the 
highest degree beneficial, as I have already had 



THE SPECIAL THEBAPEUTICS OF PAIN. 



247 



occasion to demonstrate to my entire satisfaction in 
several cases. How much may be obtained in in- 
flammatory affections of the cord only an extended 
experience can, of course, determine. In purely 
functional derangements, however, its efficacy is 
beyond question. 

In the second paper alluded to in the foot-note — 
that published in the Medical Record of March 17, 



Fig. 16. 




1888 — will be found a number of cases illustrative 
of the efficacy of this procedure. Several cases 
may also be found in the third edition of the au- 
thor's monograph on " Headache and Neuralgia." 

The Irrigation of the Cauda Equina with Me- 
dicinal Fluids. — While I was engaged in testing the 
method of medicating the spinal cord just described 
I became impressed with the desirability of intro- 
ducing remedies directly into the spinal canal, with 
a view to producing still more powerful impressions 



248 pain. 

upon the cord, and more especially upon its lower 
segment. 

As is well known to every physician, the cord, 
properly speaking, extends only to the first, or at 
most to the second, lumbar vertebra. The nervi 
lumbales, sacrales, and coccygei are therefore 
obliged to traverse a long distance within the 
spinal canal in order to attain their respective 
points of exit. It is thus that the parallel nerve- 
stems are formed at the lower end of the cord. 
These fasciculi, in their totality, constitute the so- 
called cauda equina. Now let us recall two well- 
known facts of anatomy : the first of these is that 
the pia mater, properly speaking, comes to an 
abrupt conclusion at the end of the spinal cord 
proper (the conus terminalis) ; * while the second is 
that the blind sac of the dura mater extends to the 
end of the canalis sacralis. 

"With the above data vividly before us we shall 
readily understand that when a needle is thrust 
down between the spinous processes of the third 
and fourth lumbar vertebrae, for example, close to 
the ligamentum interspinosum, the point of such 
a needle, after penetrating the dura mater, will 



1 The filum terminate has no practical bearing on the argument ; 
I therefore ignore it altogether. 



THE SPECIAL THERAPEUTICS OF PAIN. 249 

find itself directly in contact with the filaments of 
the cauda equina, which from this point downward 
occupies the space of the spinal canal. 

If such a needle be hollow and attached to a 
hypodermic syringe charged with a medicinal fluid, 
it is, moreover, evident that the solution may be 
readily deposited upon the filaments of the cauda. 
Again, there can be no doubt, especially if the injec- 
tion be made between the second and third lumbar 
vertebrae, that the functions of the lower segments 
of the cord itself may be powerfully affected in this 
manner. ¥e have only to conceive of the cerebro- 
spinal fluid being, at this point, thoroughly impreg- 
nated with the medicinal fluid and lying in direct 
contact with the pia, — we have only to conceive of 
this, I repeat, in order to be convinced of the 
potency of such a procedure. 

As to the question of possible injury arising from 
pricking the filaments of the cauda with the needle, 
it must be borne in mind, in the first place, that 
serious disturbances of sensation and motility, 
having their origin in the cauda, are always due 
to gross lesions, and not to insignificant, circum- 
scribed causes. The very fact that the cauda is 
composed of a great number of filaments, that 
these fill out the entire canal and are widely dis- 
tributed, would a priori lead us inevitably to this 



250 pain. 

conclusion, did we not know inductively from clini- 
cal histories and subsequent post-mortem investi- 
gation that such is the case. 1 

Secondly, we must remember that the wounding 
of a nerve-stem (and the cauda is nothing more 
than an aggregation of nerve-stems) with a fine, 
sharp needle is practically without significance. 
There is an interesting observation bearing on this 
point in Weir Mitcheirs well-known book on nerve- 
injuries, which we may here apply with perfect 
legitimacy. " The passage of a needle into the 
nerve of an animal causes," he says, "usually a 
little bleeding, which passes away without grave 
result." 2 

Such a statement applies to simple puncture with 
a fine needle ; wounds made with an awl or other 
coarse instrument may, of course, set up the symp- 
toms of circumscribed neuritis. 

After a survey of the various factors involved as 
above indicated, and after some preliminary ob- 
servations on animals, I decided several years ago 
to put to a practical test the possibilities of direct 

1 Vide "Injuries of the Cauda Equina," by "William Thorburn, 
M.D., Brain, vol. x. page 381 et seq. 

2 "Injuries of Nerves and their Consequences," by S. "Weir 
Mitchell, M.D., Philadelphia, 1872, page 92, nineteenth line from 
the bottom of the page. 



THE SPECIAL THEKAPEUTICS OF PAIN. 251 

medication of the cauda equina as soon as a suitable 
case should present. 

The first case in which I resorted to it was one 
of spinal irritation following an operation upon 
the urethra. I was called in consultation in the 
case ten days after the operation. At that time the 
spine was sensitive to pressure ; there were several 
points of unusual tenderness located in the lower 
dorsal and lumbar regions; while the marks of 
frequent blisterings were still visible on both sides 
of the spinous processes. Various internal reme- 
dies, such as -strychnine, ergot, and analgesics of 
different kinds, were prescribed, but without sensible 
improvement. 

The patient readily consenting, I decided, there- 
fore, to try the efficacy of an injection composed of 
Tinct. aconiti, gtt. v; cocainse, gr. ss; aquse, 3i. 
Sig. — For one injection. 

The foregoing amount of medicated solution I 
deposited directly upon the cauda equina in the 
following manner : 

A small trocar, half an inch long, and of the 
diameter of a wax match, was first thrust through 
the skin between the second and third lumbar 
vertebrae. A long, fine, hollow needle, screwed to 
an ordinary hypodermic syringe, was then passed 
through the opening in the trocar and down through the 



252 pain. 

soft tissues adjoining the ligamentum interspinosum 
till the spinal canal was entered. The trocar and 
needle are shown in Fig. 17. The entire contents 
of the syringe were then emptied upon the fibres 
of the cauda equina. 

In from five to eight minutes the subject described 
a tingling sensation in both lower limbs, slightly 
more marked, perhaps, in the left than in the right 
leg. On examination there proved to be a decided 



Fig. 17. 



=™f 



W.F.FQRDS.I.CO.N.V. 



impairment of tactile sensibility, amounting, in 
certain localities, particularly in the lower third of 
the thigh and ankle, to a positive anaesthesia. 

"Within a quarter of an hour, or at most twenty 
minutes, every remnant of pain had disappeared, 
and pressure upon the vertebrae failed to reveal any 
special degree of tenderness. These phenomena 
are certainly remarkable when we consider the 
facility and rapidity with which they were evoked. 

I will merely add that there was entire exemption 
from pain during the next thirty-six hours; and 
when the pain and tenderness finally reappeared 
they exhibited a decided diminution in acuity. 

The future course of the disease differed in no 



THE SPECIAL THERAPEUTICS OF PAIN. 253 

essential particular from that of an ordinary case 
of acute spinal irritation. Recovery was soon com- 
plete ; and, by avoiding severe bodily strain, partic- 
ularly rapid walking, sitting for a long time, or 
bending the body forward and backward, the patient 
was able to avoid relapse. 

The second case in which I resorted to local medi- 
cation of the cauda equina was one of " caisson 
disease," many exquisite examples of which I had 
the pleasure of studying at St. Francis' Hospital, 
Jersey City, as well as at Christ Hospital, to which 
institutions cases of the kind were brought during 
the construction of the Hudson River tunnel. I 
will merely mention that, in the case in question, 
the injection was made with the hope of relieving 
the severe vesical and abdominal pains which are a 
peculiarly distressing feature of certain phases of 
this remarkable disease. 

The injection was made in the same manner as 
in the previous case, but was repeated within the 
next five hours, as the pain, which was greatly, 
though not entirely, removed, showed a tendency 
to return. Within the next forty-eight hours the 
improvement was, however, so great as to render 
further local treatment for the alleviation of pain 
unnecessary. 

Since the above cases were reported I have occa- 

22 



254 pain. 

sionally resorted to the procedure in properly se- 
lected cases. 

Methods of Treatment Previously Proposed. 
— Among the older devices which have heen re- 
sorted to in the treatment of pain originating in 
the affections of the cord may be mentioned 
counter-irritation with blisters, or the actual cau- 
tery, galvanism, and faradism, hot and cold appli- 
cations, baths, — Turkish and Eussian, — and various 
internal remedies, which either act directly upon 
the cord — strychnine, ergot, etc. — or which exert 
their influence by stupefying the subject — opiates 
and hypnotics. 

To enter into a discussion of these measures 
would be merely to repeat what has already been 
said with sufficient explicitness in the chapter on 
internal remedies. 

One of the least philosophical means of dealing 
with pain is the " suspension treatment," proposed 
by Motschukowky in 1893, and subsequently en- 
dorsed by Charcot. The patient is suspended by 
the head, the arms assisting somewhat, precisely as 
though he were about to be enveloped in a plaster- 
of-Paris jacket. In this condition he is allowed to 
remain for several minutes. This manipulation 
may be repeated more or less often as circumstances 
seem to demand. The pains of locomotor ataxia 



THE SPECIAL THEEAPEUTICS OF PAIN. 255 

and other spinal symptoms are reported to have 
been relieved by this treatment ; and even cerebral 
disturbances are said to have been abolished by it. 
Hirt, however, who has used the method one 
hundred and three times in the same number of 
patients, states that in no single instance was he 
able to note any marked or lasting improvement. 
It has also been proposed to bend ataxic patients 
over barrels ; and one writer, in sheer exuberance 
of spirit, has suggested that it might be well to 
"hang them up by the heels." To accept such 
propositions as this with any degree of seriousness 
would be to prove one's self devoid of humor. 
Not even on the score of empirical evidence, much 
less on theoretical grounds, are such procedures 
likely to gain a foothold in practice. Indeed, as a 
matter of fact, the results obtained have been so 
insignificant that the suspension treatment and its 
grotesque derivatives have been practically aban- 
doned. 



CHAPTER XVII. 

THE USE OF COMPRESSED AIR IN CONJUNCTION WITH REME- 
DIES WHICH TEND TO DIMINISH THE ACUITY OF PERCEP- 
TION. 

We have already seen in the course of the pre- 
vious discussion that the effects of drugs are not 
only subject to variations dependent upon subjective 
causes, conventionally spoken of as idiosyncrasies, 
but are also capable of being greatly modified by 
extraneous circumstances, among the most impor- 
tant of which are changes in atmospheric pressure. 
Thus, we have seen that on the summit of a high 
mountain stimulants act in a different manner than 
when taken in air condensed beyond that of the 
normal atmosphere, as we find it, for example, in a 
diving-bell or in a caisson employed in the con- 
struction of submarine works. 

It is self-evident that a principle so valuable must 
be capable of practical application in neuro-thera- 
peutics, as I was the first to point out over two years 
ago. In a word, stimulants when administered 
while the subject remains in compressed air are 
256 



THE SPECIAL THERAPEUTICS OF PAIN. 257 

greatly enhanced in their pharmacodynamic effects; 
and this influence of the air begins to be felt at a 
pressure of one atmosphere and a half, and is quite 
pronounced at two atmospheres. 

But not only may this be said of stimulants, but 
also of a number of sedatives, analgesics, and diu- 
retics. 

Upon what physiological principle does this phe- 
nomenon depend ? How is it explicable ? 

The answer, in a few words, is this : 

In the first place, the air pressing upon the surface 
of the body, and also upon the parenchyma of the 
lungs, — by way of the bronchial tubes and air-vesi- 
cles, — will inevitably cause the blood to gravitate in 
the direction of the least resistance. Now, as the 
cerebro-spinal canal is to all practical intents and 
purposes an unyielding, air-tight tube, the surround- 
ing highly-compressed air is unable to exert pressure 
upon the contents of the canal, — the brain and cord; 
and hence the blood will gravitate to these organs, 
— i.e., in the direction of the least resistance. The 
result of this will be a notable enhancement of vaso- 
motor pressure with concomitant increase of exos- 
mosis ; so that, if the blood be impregnated with a 
medicament, the latter will penetrate with greater 
rapidity than under ordinary circumstances through 
the cell-wall and into the surrounding parenchyma. 

r 22* 



258 pain. 

An increase of physiological effect is, of course, the 
inevitable result of such augmented transudation in 
the cerebro-spinal structures. 

But there is another principle connected with the 
action of remedies upon the central nervous system 
which is important both theoretically and practi- 
cally; I refer to the fact that stimulants and seda- 
tives act much more energetically when caused to 
linger in the nervous tissues, or, what is the same 
thing, in the capillaries which supply those tissues. 
Let me illustrate this point. Some years ago I was 
called to see a woman — the wife of a hotel clerk — 
who was a sufferer from neuritis of the brachial 
nerve, due, probably, to traumatism. The chief 
seat of irritation was at a point about three inches 
above the internal condyle of the humerus. Twenty- 
five grains of antipyrin, with ammonia, were given 
with a view to arresting the pain, but without avail. 
Being desirous of avoiding the use of morphine, I 
passed a ligature around the arm two inches above 
the seat of pain, tightening it sufficiently to interfere 
considerably with the venous circulation. At first 
there was some increase of pain; but gradually it 
began to decrease, and ultimately — within fifteen 
minutes — it disappeared entirely, so that the liga- 
ture was removed. In this case the ligature was 
applied nearly three-quarters of an hour after the 



THE SPECIAL THERAPEUTICS OF PAIN. 259 

administration of the antipyrin by the mouth, so 
that most, if not all, of the remedy mast have been 
absorbed. The effect of the ligature was to so retard 
the circulation in the capillaries that the antipyrin 
contained in the blood was enabled to fully exert its 
characteristic anaesthetic effects upon the inflamed 
nerve-filaments. 

Now, what is true of the peripheral nerves in 
this regard is likewise true of the central nervous 
system. This is shown by the fact that if we ad- 
minister a remedy like alcohol, and subsequently 
partially interrupt the flow in the internal jugular 
veins by compression, the physiological effects of 
the drug are materially augmented. 

From what has been said, it is evident that if we 
could practically combine these two principles — 
increased vaso-motor pressure and retardation of 
the medicated blood-stream in the capillaries of the 
locality to be most affected — we should be placed in 
possession of a most potent means of influencing 
the nervous system, and more especially the 
brain. 

Recognizing the importance of the subject, I have 
sought to combine these two cardinal principles: 
first, by exposing the subject in a metal chamber, 
containing compressed air; and, second, by inter- 
rupting the venous circulation in those parts which 



260 pain. 

it is desired should be brought most fully under the 
influence of the remedy. 

Let me describe in detail the rather elaborate 
apparatus which I employ in carrying out this plan 
of treatment ; and let me also add that the proced- 
ure as here presented differs somewhat from that 
originally described in the Medical Record of August 
29, 1891. 

The Author's System of using Compressed Air, 
in Conjunction with Medicinal Solutions, in the 
Treatment of Cerebro-Spinal Affections of Func- 
tional Origin. — In the first place, I have had con- 
structed a large metal chamber, capable of hermetical 
closure, and able to withstand a pressure equal to 
that of a locomotive boiler (Fig. 18). This chamber 
is cylindrical; it is six feet in diameter, six and 
one-half feet high, and its walls are composed of 
soft steel. The ends of the cylinder, which com- 
pose the top and bottom of the chamber, are five- 
eighths of an inch in thickness, while the cylindrical 
walls are somewhat less heavily constructed. The 
seams are not secured by rivets, but by bolts, so 
that the chamber was brought into my house in 
sections, and erected in one of the consulting-rooms 
without noise or other disturbance. 

Access to this chamber is afforded by a massive 
door, swung from the centre upon ponderous hinges, 



THE SPECIAL THERAPEUTICS OF PAIN. 



261 



which peculiar arrangement admits of a very exact 
coaptation of the door to its frame. The edges of 
the latter are, of course, armed with a thick roll of 



Fig. 18. 




india-rubber. To further insure a hermetical closure 
an adjustable cross-lever has been provided, so that 
a screw, acting by the aid of a hinge from the centre 
of the door upon this lever or cross-bar, enables one 



262 pain. 

to draw the door — which opens inwardly — firmly 
against its frame. 

The ingress and egress of the air, which is derived 
from a pump actuated by an electric motor of one 
horse-power, are regulated by adjustable valves. By 
this arrangement it is possible to accurately regulate 
the amount of air-pressure deemed applicable in a 
given case. In addition to these appliances a safety- 
valve and pressure-indicator have also been pro- 
vided. The amount of pressure commonly employed 
is, however, vastly below the maximum point of 
endurance of the chamber, which, on account of 
its unusually solid construction, is capable of with- 
standing enormous strains. How great is this 
strength may be gleaned from the fact that, in its 
completed condition, it weighs over three tons. I 
feel that great credit is due to the Cockburn Barrow 
and Machine Company, of Jersey City, for the con- 
scientious manner in which they have performed 
this portion of the work. As is well known to the 
engineering fraternity, this firm has had an exten- 
sive experience in the use of compressed air in 
caisson- and tunnel-work, notably, in the case of 
the Hudson River tunnel and the foundation-work 
of the Hatteras light-house. It gives me pleasure to 
acknowledge my special indebtedness to Mr. Wil- 
liam C. Barr and Mr. D. B. S. Cockburn, both of 



THE SPECIAL THEKAPEUTTCS OF PAIN. 263 

whom have been assiduous in their endeavors to 
render the mechanical details all that they should be. 

I cannot leave this portion of the subject with- 
out indicating briefly the principal features of the 
mechanism employed in condensing the atmosphere 
within the chamber. For this purpose I have had 
placed in the cellar of my house a one-horse-power 
electric motor, actuated by the current derived from 
the street conduit of the Edison Electric Illumi- 
nating Company. To the motor is joined, by appro- 
priate belts and counter-shafting, an air-pump (Fig. 
19) of superior construction, and with a capacity 
of more than one hundred and forty strokes to 
the minute, the length of each stroke being six 
inches, and the diameter of the cylinder of the 
pump being also six inches. 

By the aid of a system of wires, switches, and a 
resistance-box one is able to start this mechanism 
from the floor above, in the immediate vicinity of 
the air-chamber, without the slightest danger of 
causing a derangement of the belts and pulleys em- 
ployed in joining the pump and motor together. 

A strong tube of iron conducts the air from the 
pump through an aperture in the floor to the metal 
chamber; while a similar tube affords passage for 
the redundant air from the automatic exhaust-valve 
previously described. It is possible, in this way, 



264 



PAIN. 



to obtain pressures of from fifteen to thirty pounds 
in a few minutes. 

It gives me pleasure to express my indebtedness 
to Mr. Hadley, of the Edison Electric Illuminating 



Fig. 19. 




Company, who has superintended this elaborate 
installation with much diligence and skill. 

Let me now describe, in as few words as possible, 
the manner in which I am accustomed to employ 
this apparatus, in conjunction with medicinal solu- 
tions, for the purpose of increasing and adding 



THE SPECIAL THERAPEUTICS OF PAIN. 265 

permanency to the pharmaco-dynamic effects of the 
latter. 

For convenience' sake, we may assume that we 
have to deal with a severe case of the so-called 
angio-spastic variety of hemicrania, — that form of 
migraine accompanied by facial pallor which is sup- 
posed by some to be the counterpart of partial 
intracranial ansemia. 

Twenty-five grains of antipyrin, with ammonia, 
have been given the patient, who is suffering acutely; 
and yet, after the lapse of over three-quarters of an 
hour, — a period of time amply sufficient to insure 
absorption, — there is little, if any, relief. At this 
juncture he is placed upon a couch within the air- 
chamber, and around his neck is passed a light 
elastic band, secured behind by an ordinary buckle. 
The function of the band is to maintain in place, 
over the jugular veins, two small dry cups. The 
cups, which are joined together in front by a slotted 
band provided with a screw, are about two inches 
long and half an inch wide; they are made of 
metal, — silver or steel, — and are somewhat concave 
in an antero-posterior direction, on the open side, 
which is in immediate contact with the tissues above 
the veins. On the upper or closed side is a hollow 
nipple connecting with the interior of the cup. A 
long, bifurcated, non-collapsable rubber tube joins 
m 23 



266 



PAIN. 



these nipples to a small valve in the wall of the air- 
chamber, by opening which the interiors of both 
cups are placed in communication with the external 
atmosphere. For the time being, however, this 



Fig. 20. 




valve remains shut ; the door of the air-chamber is 
closed; and the air-pump is set in motion. After 
the lapse of a few moments, the gauge shows that 
we have eight pounds more pressure in the air- 
chamber than outside of it, or 15 pounds + 8 pounds 
= 23 pounds. 



THE SPECIAL THERAPEUTICS OF PAIN. 267 

The small valve in the side of the air-chamber, 
which is connected by the bifurcated rubber tube 
with the dry cups, is then opened, and its immediate 
result is to place the interiors of the cups in com- 
munication with the external atmosphere. As a 
result of this the pressure inside the cups is only 
fifteen pounds, while that outside is twenty-three 
pounds; and the difference between the two, eight 
pounds, is the amount of pressure exerted upon 
each square inch of cup, and, consequently, upon 
the subjacent veins. The effect of the manoeuvre 
is, however, much enhanced by the fact that the 
tissues of the neck, and, to some extent, the veins 
also, are drawn in an upward direction by the cups, 
so that the edges of the latter act energetically upon 
the lumen of the vessels. The pneumatic jugular 
compressor, and its use in conjunction with the air- 
chamber, are well shown in Fig. 20. 

In the case of the patient under consideration, 
the hemicrania disappeared completely after the 
pressure upon the jugular had been continued five 
or six minutes ; and there remained no other souve- 
nir of its presence than the usual feeling of soreness. 
Nevertheless, although compression was discontin- 
ued, the patient was allowed to remain in the com- 
pressed air for another half-hour, as experience has 
taught me that this is a useful precaution in the 



268 pain. 

management not only of migraine, but all kinds of 
intracranial pain due to other than organic changes. 
Indeed, it is well, when there is reason to fear a 
recurrence of the pain, to still further increase the 
air-pressure, say up to two atmospheres ; for by so 
doing it is self-evident that modifications in the 
cerebral circulation may be attained of sufficient 
importance to materially modify the morbid condi- 
tions. These are not theoretic deductions, but they 
are rather conclusions at which I have arrived after 
a vast deal of experience. 

A brief synopsis of a few cases in which I have 
invoked this method of employing compressed air 
for arresting intracranial pain may not prove unin- 
teresting. 

Mrs. BF. J. G., age forty-four years, the wife of a 
distinguished clergyman, was referred to me by 
Dr. David Webster, over a year ago, on account 
of intractable head-pain of several years' duration. 
The pain usually begins over the right eye, and 
extends backward to the temple, and thence to the 
right occipital region. More rarely it is also felt 
over the left eye, but, as a rule, it is hemicranial in 
type. 

Although she has received benefit from the cor- 
rection of a refractive error (hypermetropic astig- 
matism) at Dr. Webster's hands, she still suffers at 



THE SPECIAL THERAPEUTICS OF PAIN. 269 

irregular intervals, even moderate emotional dis- 
turbance being sufficient to call forth a paroxysm 
of great severity. While the seizure lasts, her face 
is slightly flushed; and, as she is quite thin, the 
pulsation of the carotids is visible to the eye. She 
has been under the care of a number of physicians 
at different times ; has been operated upon for lacer- 
ation of the cervix, without apparent benefit; and 
has taken a large assortment of internal remedies, 
likewise without result. Having found no evidence 
of organic trouble of any kind, I requested her to 
return at the first intimation of impending pain. 
Accordingly, Rve or six days later, she again called, 
suffering from an attack which had come on during 
the early morning hours. As a matter of scientific 
interest I applied pressure to the jugulars, — but 
ivithout previous medication, — as heretofore described, 
for fifteen minutes, and then, having ceased the 
compression, she was allowed to remain in the 
compressed air (of two atmospheres) for upward of 
three-quarters of an hour. At the end of this time 
pressure was gradually reduced; and she declared 
on coming out that she felt relieved, but not wholly 
so. Accordingly, after allowing her to wait for 
an hour, I gave her fifteen grains of antipyrin in 
ammonia, — which she had often tried before, but 
without success, — applied compression to the jugu- 

23* 



270 pain. 

lars, and had her remain in the compressed air at 
two atmospheres for an hour. On leaving the 
chamber at the end of this time she declared that 
all pain had entirely left her. Her diet having 
been restricted to poultry, fish, and vegetables easy 
of digestion, the compressed-air treatment was con- 
tinued, with the occasional addition of two drachms 
of the extract of absinthe, as she suffers much from 
depression. 

As a result, there was no pain whatever for 
nearly a month, so that on April 9, 1892, Dr. 
Webster wrote me that " she had called to say that 
she had been much benefited by the compressed-air 
treatment." 

From what I have since seen of her, I am inclined 
to believe that this benefit has become permanent. 

Mr. L. was likewise referred to me by Dr. David 
"Webster on account of "paralysis of his left third 
nerve," accompanied by persistent headache. There 
is a distinct history of syphilis, imperfectly treated, 
so that both symptoms are doubtless of specific 
origin. 

Though he has been treated with large doses 
of the iodide with considerable benefit, Dr. Webster 
feels that applications of electricity to the affected 
muscle should also be tried. 

I first saw this patient October 31, 1892; and, on 



THE SPECIAL THERAPEUTICS OP PAIN. 271 

referring to my case-book, I find that on November 
5 I had made five applications of faradism, which 
had resulted in an abolition of double vision for 
several hours. 

On the same date he was seen by Dr. Webster, 
who wrote me, "Mr. L. shows marked improve- 
ment. When I sent him to you it took 40° base 
in and 18° base down to correct the deviation. 
To-day it takes 33° base in and 14° base down over 
left, a gain of 7° in one direction and 4° in the 
other." 

The headaches, too, had improved under one- 
hundred-grain doses of the iodide of potash; but 
he still suffered at times from exacerbations of 
severe pain. These I was always able to abolish 
for several hours by the use of fifteen grains of 
antipyrin, given under an air-pressure of an atmos- 
phere and a half; while the internal jugulars were 
compressed pneumatically, as in the previous case. 
The same amount of this drug had been repeatedly 
given before, — without the use of the compressed 
a i r> — and the effect, so far as amelioration of the 
pain was concerned, was nil. 

It may readily be imagined that, while the iodide 
was the principal thing, the compressed-air treat- 
ment rendered valuable assistance in a collateral 
way by relieving the severe pain while the alterative 



272 pain. 

was doing its work. Eventually, both the head- 
pains and the diplopia disappeared entirely. 

Miss H., referred by Dr. Koplik, was first seen by 
me May 6, 1893. The doctor writes "that she is 
a patient suffering from periodic headaches," for 
which " she has tried many physicians, both in 
Germany and elsewhere, but found no relief." 

Since puberty she has suffered periodically — on 
an average every five or six days — from these head- 
aches, which, beginning as a dull pain over the left 
eye, progress to the temple and side of the head, 
where they usually remain fixed for twelve hours, 
and then suddenly disappear. They are always 
accompanied by sickness of the stomach, and occa- 
sionally by vomiting. In the beginning they are 
dull, but later, lancinating in character. 

After trying a number of conventional expedients 
without much success, I determined to endeavor to 
abolish, or at least mitigate, the seizures by the aid 
of the compressed air. 

Accordingly, she was told to come at once to the 
office on the first intimation of an attack. This she 
did in the course of three or four days, the pain 
being firmly seated, and exceedingly severe at the 
time of her arrival. As she suffered from nausea, 
she was given one-fourth grain of cocaine in a tea- 
spoonful of water to which ten grains of the bicar- 



THE SPECIAL THERAPEUTICS OF PAIN. 273 

bonate of soda were added. This seemed to relieve 
the nausea considerably, so that in half an hour it 
was possible to proceed with treatment. Fifteen 
grains of salipyrin were given her, and half an 
hour afterwards she entered the air-chamber, where 
compression of the jugulars was carried out, as in 
the previous cases, for fifteen or twenty minutes. 
The compressor was then removed (by the patient), 
and the air condensed to two atmospheres, at which 
point it was maintained for an hour. Pressure was 
then gradually reduced, and the patient removed 
from the chamber. She then declared that shortly 
after the compression of the jugulars the pain had 
been much relieved in severity, and at the time 
of leaving the chamber it had been entirely abol- 
ished. 

This was the most severe attack which she experi- 
enced while under my observations. Ultimately they 
seemed to lose their vehemence to such a degree that 
I am confident proper attention to diet and the occa- 
sional use of simple remedies will do much for her. 

In view of this amelioration in the severity of 
the attacks, which is even more marked in some 
other cases which I have seen, I cannot repress the 
conviction that the air itself, through its influence 
on the circulation in the interior of the body, must 
tend to readjust — for I can find no better word — 



274 pain. 

any nutritive disturbances of a local character in 
the cerebral organs or their appendages. Certainly 
the simple drug alone could hardly be expected to 
accomplish so much. The hyperdistention of the 
capillaries in the cerebro-spinal organs, consequent 
upon the increased vaso-motor tension during treat- 
ment, has doubtless much to do with this continued 
improvement. 

These are fair examples, then, of the way in 
which remedies may be made to concentrate their 
effects upon the intracranial structures. In all 
but very fleshy persons the method is readily appli- 
cable ; but when the adipose covering of the neck 
is very dense it is impossible to act upon the in- 
ternal jugulars with any degree of certainty, and 
without great inconvenience to the patient. 

In conclusion, let me add that the chief field of 
usefulness of the method is in the management of 
intracranial pain of a severe type. When it is a 
question of dealing with head-pain, combined with 
spinal symptoms, as often enough happens, or with 
melancholia or neurasthenia, the procedure origi- 
nally advocated by me in 1891 should be invoked. 

As completeness of the argument demands a 
presentation of this system of affecting the cerebro- 
spinal axis, I shall proceed to describe it as briefly 
as possible. 



THE SPECIAL THEEAPEUTICS OF PAIN. 275 

Showing" how Compressed Air may be used to 
Advantage where it is desired to Focalize the 
Action of Remedies upon the Entire Cerebro- 
spinal Axis — Application of the Principle of Ex- 
clusion. — In carrying out the exigencies of this 
problem we are obliged to invoke a somewhat dif- 
ferent principle than when it is desired to concen- 
trate the action of remedies upon the brain : to put 
it succinctly, we cannot compress the medullary 
veins, and hence we are obliged to resort to exclu- 
sion, — i.e., cut off certain portions of the economy, 
such as the limbs, from the field of activity of the 
remedy. This we may do by the application of 
ligatures to the extremities. Let us examine some- 
what more closely the principle of action with which 
we are here confronted. 

In the first place, it must be remembered that the 
amount of ether, chloroform, chloral hydrate, the 
bromides, strychnine, and many other remedies re- 
quired to produce physiological effects upon the 
cerebro-spinal mechanism, may be reduced by first 
securing a ligature around the central portion of 
one or several of the limbs of an animal, so as to 
interrupt both the arterial and the venous circula- 
tion. 

The proof and explanation of this may be thus 
presented : 



276 pain. 

In the first place, it is well known that children 
and small animals are affected by much smaller 
quantities of anaesthetics and other medicinal sub- 
stances than are required to produce equal effects in 
men and large animals. 

At first sight there appears to exist a certain defi- 
nite relation between the weight of the animal and 
the quantity of medicament required to produce 
physiological effects. On closer inquiry, however, 
we find behind this proposition the deeper truth 
that the real proportion is between the magnitude of the 
blood-mass and the amount of medicament. . Thus, if 
we withdraw a considerable amount of blood from 
a large dog, we may be able to influence him by 
much smaller doses than those required under ordi- 
nary circumstances ; and, among human beings, we 
find the anaemic much more susceptible to remedies 
than the full-blooded of equal weight. The degree 
of saturation of the blood-mass with the remedy is 
obviously, then, the principal thing; the greater 
the amount of blood, the more remedy — everything 
else being equal — we shall have to give in order to 
obtain definite results. 

If we wish to embody the proposition in a mathe- 
matical statement, we may do so in the following 
simple manner : 

Let a represent the total quantity of blood, b the 



THE SPECIAL THEKAPEUTICS OF PAIN. 277 

amount of remedy exhibited, and x the magnitude 
of the physiological effect. We shall then have the 

simple formula x '= -. 
a 

Again, if we withdraw a certain quantity of blood 

from the circulation by venesection, and call that 

amount d, we shall then have the formula x = 7 . 

a — a 

But, if we wish to act upon the organs of the trunk, 
and more especially upon those contained within 
the cerebro-spinal canal, it is not necessary to resort 
to such a drastic expedient as copious blood-letting ; 
for, in place of this, we may dam up and effectually 
eliminate from the rest of the body a certain amount 
of blood by passing a ligature around the central 
portion of one or several extremities, so as to inter- 
rupt the circulation in both artery and vein. When 
this has been done, it is clear that we may introduce 
a remedy into the system by way of the stomach, 
or hypodermically into some portion of the trunk ; 
and it is equally certain that a remedy so introduced 
will be diluted only in the ratio of the amount of 
blood freely circulating, and more especially by that 
contained within the trunk and head. That which 
is incarcerated behind the ligatures is as effectually 
withdrawn from the realm of physiological action 
as though it had been abstracted by the surgeon's 

24 



278 pain. 

knife. Elimination by the knife and elimination 
by the ligature are, for present purposes, then, one 
and the same thing. Hence, if we let d! represent 
the amount of blood incarcerated behind the liga- 
tures, x the magnitude of the physiological effect, 
which we are seeking, b the amount of remedy ex- 
hibited, and a the total amount of blood contained 
in the whole organism, we shall have the formula 

x = —b— b 

a — d! a — d' 

Several years since I had an excellent opportunity 
of proving the truth of the foregoing, in connection 
with the administration of ether, in the case of a 
patient who resisted all attempts to anaesthetize him 
in the ordinary way. 

The case in question was a man under treatment 
at the Manhattan Eye and Ear Hospital, upon whom 
it was deemed advisable to perform an operation. 
As has been said, the ordinary means of inducing 
anaesthesia had proven ineffectual, for the man was 
a confirmed drunkard; and it was at this juncture 
that I was called in consultation, and requested by 
my friend Dr. David Webster, one of the surgeons 
of the hospital, to endeavor to devise some means 
of getting the man under the influence of the anaes- 
thetic. 

The procedure which I suggested was this: 



THE SPECIAL, THERAPEUTICS OF PAIN. 279 

Around the upper part of each thigh a flat rubber 
tourniquet was tightly drawn, and secured in place 
in the usual manner. By this means the sequestra- 
tion of all the blood contained in the lower limbs 
was accomplished; but, inasmuch as both artery 
and vein were compressed, only the amount of 
blood usually contained in each limb was shut off 
from the rest of the body, — which would not have 
been the case had we contented ourselves with 
merely compressing the veins, as some have done. 1 
In subsequently commenting on my published re- 
port of this case, that most accomplished writer 
and physician, Henry M. Lyman, — than whom 
there is no greater authority on anaesthesia, — ob- 
serves that the plan proposed and adopted by me 
on this occasion (that of compressing both vein and 
artery) is far preferable to compression of the vein 
alone. 

The reason for this is not far to seek. When 
we compress the veins alone there is a rapid accu- 
mulation of blood in the extremities, through the 
accessions derived from the uninterrupted arteries. 
Now, as this blood is derived from the trunk, and, 



1 " On the Effective and Kapid Induction of General Anaesthe- 
sia," the New York Medical Journal, October 22 and December 24, 
1887. 



280 pain. 

consequently, also from the organs contained within 
the cerebro-spinal canal, there is danger of syncope, 
and even heart-failure. When, on the other hand, 
both artery and vein are compressed no such deriv- 
ative action occurs, and all danger is consequently 
removed. With an apology for this brief digression, 
I now return to the interesting case which has given 
rise to it. 

Having, as previously stated, applied tourniquets 
to the central portion of the lower limbs, the ether- 
cap was placed over the mouth and nose of the 
patient, and in an incredibly short time he was 
unconscious, and the surgeons were able to go on 
with the operation. 

The late Dr. Cornelius R. Agnew and many other 
members of the staff of the hospital were present, 
and gave emphatic expressions of approval. 

Dr. F. W. Ring, assistant surgeon to the Man- 
hattan Eye and Ear Hospital, declared that both 
the amount of ether and the time consumed in its 
administration were infinitesimal, when compared 
with what had been expended in previous efforts at 
inducing anaesthesia in the usual way. The facts 
brought out on this occasion with regard to the 
administration of ether have since been repeatedly 
verified by different observers ; so that at the pres- 
ent day their validity cannot be questioned. I 



THE SPECIAL THEEAPEUTICS OF PAIN. 281 

desire to add, however, that I have long known 
that the dosage of phenacetin, antipyrin, morphine, 
chloralamid, chloral, the bromides, and many other 
remedies might be reduced by resort to the same 
procedure; all of which is merely equivalent to 
stating that their pharmaco-dynamic energy may be 
increased in this way. 

The reduction of the amount of blood to be 
impregnated with the remedy, by the application 
of ligatures to the extremities, and the concurrent 
exposure of the subject to the influence of com- 
pressed air, so as to increase the vaso-motor tension 
of the medicated regions, — i.e., interior of trunk and 
cerebro-spinal canal, — constitute, then, the essential 
features of this plan of medication. By invoking 
its aid melancholia, the lassitude of neurasthenia, 
and pains of an ambulatory character, as well as 
those of definite spinal or cerebro-spinal type, may 
be treated with an effectiveness attainable in no 
other way. 

Let me now describe, in as few words as possible, 
the manner in which I am accustomed to employ 
this apparatus, in conjunction with medicinal solu- 
tions, for the purpose of increasing their pharmaco- 
dynamic effects, more especially as related to the 
cerebro-spinal functions. 

As stated at the beginning of the argument, 
24* 



282 pain. 

I esteem it of advantage, before introducing the 
remedy into the system, to sequestrate a certain 
amount of blood in one or more of the extremities. 
This may be done by passing a ligature around the 
limb so as to arrest the circulation in both artery 
and vein; or the ligature may be drawn only suffi- 
ciently tight to check the circulation in the cuta- 
neous veins alone. While in the latter case the 
ligature is much better borne than in the former, 
so that it may be worn for protracted periods with- 
out inconvenience, it possesses the inconvenience 
that it causes an abnormal accumulation of blood 
in the extremity y with consequent inordinate exsan- 
guination of the trunk, and hence of the spinal cord 
and brain. To avoid this depleting influence, how- 
ever, it is only necessary to have the patient apply 
a moderately tight bandage, in the form of an elastic 
stocking or sleeve (when the ligatures are applied 
to the arms), before adjusting the ligature (Fig. 21). 
In this way stasis of the blood circulating in the 
veins may be obtained without depleting to any 
considerable extent the brain or cord, and without 
special inconvenience to the patient, provided that 
the elastic stocking or bandage has been applied in 
such a way as not to compress the veins, but merely 
to limit their expansion. This point I hope to have 
made sufficiently intelligible. The ligatures having 



THE SPECIAL THERAPEUTICS OF PAIN. 283 

been applied, and the medicinal solution adminis- 
tered, — either by the mouth, rectum, or hypodermi- 
cally, — the patient enters the pneumatic chamber, 
the air-pump is set in motion, and by degrees the 

Fig. 21. 



condensation of the atmosphere progresses until the 
desired pressure is obtained. When this point is 
reached the redundant air passes off through the 
blow-off valve, which, as previously mentioned, is 
automatic in its action, and readily adjustable to 
any desired pressure. 



284 pain. 

I have rarely deemed it necessary to employ 
greater pressure than thirty pounds to the square 
inch (two atmospheres), and I often employ lower 
ones, especially when the delicate state of the pa- 
tient's health seems to demand such a course. How 
long should the patient remain in the condensed 
atmosphere? This question cannot be answered 
dogmatically : as a rule, an hour will be sufficient 
to insure an active therapeutic effect; but, excep- 
tionally, I have allowed the patient to remain in 
the air-chamber for two hours or more. 

And now let me add a few injunctions respecting 
the precautions to be observed in connection with 
the removal of the patient from the air-chamber 
into the normal atmosphere. In the first place, it 
is of the utmost importance that this transition 
from an atmosphere of high to one of relatively 
low tension should be gradually accomplished. To 
this end the air should be allowed to escape very 
gradually, so that from fifteen to twenty minutes 
are consumed in the operation of reducing the 
pressure in the chamber to that of the external 
atmosphere. While the reduction of pressure is 
in progress the tourniquet or straps employed in 
compressing the vessels are removed, but the 
elastic stockings (or bandages) are allowed to re- 
main. 



THE SPECIAL THERAPEUTICS OF PAIN. 285 

It is also sometimes advisable to have the subject 
swallow thirty drops of spiritus ammonise aromati- 
cus, in water, at this time ; for, as the pressure de- 
creases, there is always a diminution in the energy 
and number of the heart-beats. 

This cardiac stimulant stands properly prepared 
upon a table in the air-chamber, and the patient is 
instructed beforehand when and how to take it. 
The combined effect of the elastic compress and the 
cardiac tonic is to increase the vaso-motor pressure 
in the cerebro-spinal system of vessels at the very 
moment when the compressed air is ceasing to per- 
form that function. As a result of these precautions 
I have yet to meet with a single untoward effect 
from this system of treatment. 

Finally, the ventilation in the air-chamber should 
be carefully looked to, so as to avoid the inordinate 
accumulation of carbonic acid gas in the chamber, 
and hence in the system ; for when the tissues — and 
more especially those of the cerebro-spinal system — 
are overloaded with carbonic acid, grave disturb- 
ances of function may be induced, which manifest 
themselves after the subject leaves the compressed 
atmosphere. It is ignorance or disregard of this 
fact, in connection with submarine work, which 
has, I believe, given rise to many cases of severe 
caisson disease. 



286 pain. 

In the elaborate and roomy apparatus which I 
employ there is fortunately no danger of this or any 
other kind of accident, since the circulation of air 
is continuous, and the pressure capable of exact and 
automatic regulation. 

The next question which naturally suggests itself 
is, "What are the remedies most suitable to be 
administered under pressure, where a direct action 
upon the nervous system, and especially the cerebro- 
spinal system, is sought after ?" This question has 
already been referred to at the beginning of this 
chapter, but I should like to answer it somewhat 
more explicitly. In the first place, all chemicals 
which possess an affinity for nervous matter, as 
revealed by their ability to modify the functions of 
the central and peripheral nervous system, more 
especially the former, may be given with advantage 
while the subject remains in a condensed atmos- 
phere. When I say that such substances may be 
given with advantage in this way, I mean that the 
intensity and permanency of their effects may be 
thus enhanced; or, in other words, they may be 
given with equal if not greater effect in much 
smaller doses, and the benefit derived lasts much 
longer. 

A moment's reflection will suffice to convince any 
thoughtful physician of the significance and magni- 



THE SPECIAL THERAPEUTICS OF PAIN. 287 

tude of these things from a practical point of view. 
It is, indeed, at once apparent that the discovery is 
capable of a wide application in the treatment of 
nervous derangements, especially those involving 
the brain or cord, or both. I have said that the 
remedies may be given hypodermically, by the 
mouth, or per rectum. I may add, however, that 
their exhibition by the mouth, dissolved in some 
diffusible stimulant of an alcoholic nature, is to be 
commended. 

Illustrative Cases. — A brief synopsis of a few of 
the cases in which I have resorted to this system 
of treatment will best serve to give an idea of its 
effectiveness and wide applicability. 

Case I. Pain due to Morbid Irritability of the Cord; 
Spinal Irritation. — Miss C, aged forty-five, had 
been treated by a number of physicians for obstinate 
dorsal and intercostal pain. The cautery, galvan- 
ism, and all the usual drugs, including strychnine, 
had been tried without avail. She was brought to 
my consulting-room by one of my former patients, 
whom I had been fortunate enough to cure of obsti- 
nate headaches. 

On physical examination I found the spine tender 
on pressure in the cervical, dorsal, and lumbar re- 
gions; while such paresthesia as tingling, numb- 
ness, and "burning" pains were promptly evoked 



288 pain. 

when she attempted to walk or bend the trunk 
forward or laterally. 

These symptoms had manifested themselves more 
or less constantly for the past three years ; but there 
was no evidence of any organic alteration involving 
the nervous system. The pulse was somewhat 
sluggish, but the heart and lungs and the kidneys 
were healthy. 

While the interview was still in progress she 
complained of feeling a great deal of pain, and 
wishing, if possible, to afford her some relief, I 
gave her twenty grains of antipyrin in a teaspoon- 
ful of the aromatic spirits of ammonia, well diluted 
with water. Although she was somewhat ansemic, 
there was no unpleasant symptom; but, unfortu- 
nately, neither was there the slightest relief, the 
pain persisting as energetically as before. 

On the following morning she was again brought 
to my office in a carriage. Learning that she still 
suffered from the painful paroxysm of the day 
before, I gave her ten grains of antipyrin in a little 
alcohol, applied two ligatures above the knees, and 
then installed her upon a comfortable couch within 
the air-chamber. During the first fifteen minutes 
the pressure reached eight or ten pounds to the 
square inch. Subsequently it was increased to 
twenty-five pounds, which point it was not allowed 



THE SPECIAL THEKAPEUTTCS OF PAIN. 289 

to pass, the blow-off valve being adjusted to that 
purpose. After remaining in the condensed atmos- 
phere for three-quarters of an hour, the pressure 
was gradually reduced; and fifteen minutes later, 
the equilibrium between the air in the chamber and 
the external atmosphere being established, she rose 
from the couch and passed through the open door 
without assistance. She then stated to me in the 
most positive manner that not only was she now 
quite free from all discomfort, but that she had been 
quite relieved of pain after the first fifteen or twenty 
minutes of her sojourn in the condensed atmos- 
phere. 

There being no considerable return of pain the 
following day, treatment was continued as before, 
except that one-twentieth grain of the sulphate of 
strychnine was given hypodermically, instead of the 
antipyrin, before entering the condensed atmos- 
phere. She was also placed upon the albuminate 
of iron and quinine, both of which she took for 
some time after the principal meal. 

At the end of three weeks, there being no return 
of pain, she was allowed to discontinue treatment. 
Quite a long time has elapsed since then, but she 
writes me that she is quite well, and has gained 
considerably in weight. 

Case II. A Case of Nervous Headache promptly 
n t 25 



290 pain. 

relieved. — This case is cited merely to show how 
promptly a distressing phase of headache may be 
relieved by this plan of treatment, with a minimum 
of drugging. 

Mrs. D. E., a married lady forty years of age, 
has suffered from severe attacks of headache of a 
"nervous" type for many years. As a rule, the 
paroxysm begins with more or less visual disturb- 
ance, the sight becoming clouded ; and all attempts 
to use the eyes are followed by marked feelings of 
discomfort in the eyes and head. Nevertheless, 
there are no tangible ocular defects ; the pain is not 
located in the eyeballs, but is ambulatory, predomi- 
nating at times in the occipital region, at others in 
the forehead. The circulatory disturbances are 
inconsiderable, and do not merit special attention, 
either from an etiological or therapeutic point of 
view. 

Although all the usual remedies have been tried, 
she has, until within the past six months, derived 
the greatest benefit from the use of the bromides. 
For some time, however, these have failed to abort 
the attacks of pain, so that she now refuses to 
further continue their use. 

By dint of some persuasion, I finally induced her 
to take something less than her usual dose of the 
bromide of potassium, the constricting ligatures 



THE SPECIAL THERAPEUTICS OF PAIN. 291 

being first placed above the knee and elbow, and 
the elastic stockings being just tight enough to pre- 
vent inordinate distention of the vessels. In this 
way a very complete stasis of the circulation in the 
superficial veins of all four extremities was ob- 
tained; so that the amount of blood sequestrated, 
and hence uncontaminated by the drug, must have 
been considerable. On the other hand, the elastic 
stockings served to prevent any appreciable exsan- 
guination of the cerebro-spinal axis or the trunk as 
a whole, as was shown by the carotid pulse remain- 
ing unaltered. 

Twenty minutes after taking the remedy the 
patient declared that she was no better. She was 
then placed in the air-chamber, and the pressure 
increased to fifteen pounds to the square inch, at 
which point it was maintained for nearly half an 
hour. The pressure was then gradually reduced, 
as she intimated that the pain had entirely left her. 

Case III. A Case showing that the Effects of Alco- 
hol may be greatly enhanced by exposing the Subject 
in a Condensed Atmosphere. — R. E. A., a young un- 
married man, has been addicted to the habitual 
abuse of alcohol for many years. He states that at 
the present time he is obliged to take double the 
quantity which he formerly drank in order to obtain 
the slightest stimulating effect. I had him indicate 



292 pain. 

on a tumbler his usual dose ; and, as there exhibited, 
it could not have been less than two ounces, his 
tipple being whiskey or brandy. Wishing to ascer- 
tain whether in so old an habitue the compressed 
air might be invoked as an aid to decreasing the 
amount of alcohol taken at one time, I gave him 
half his accustomed dose of whiskey, and had him 
enter the air-chamber (without ligatures or elastic 
stockings). The pressure was then gradually in- 
creased to eighteen pounds to the square inch, and 
at this point it was maintained for twenty minutes, 
the air being renewed from time to time to insure 
a plentiful supply of oxygen. It was then gradu- 
ally decreased till the pressure within the chamber 
equalled that of the external atmosphere. The 
door was now opened, the patient having been ex- 
posed to the influence of the condensed atmosphere 
for forty-five minutes, and to a maximum pressure 
of eighteen pounds for twenty minutes. He then 
stated that he was certain that the degree of exhila- 
ration experienced was quite equal, if not greater, 
in degree to that usually derived from twice or even 
thrice the quantity of alcohol exhibited under ordi- 
nary circumstances. 

The capital significance of such an observation as 
the foregoing will, I am sure, impress itself upon 
every thoughtful practitioner. 



THE SPECIAL THERAPEUTICS OF PAIN. 293 

Case IV. A Case showing the Beneficial Influence 
of this System of Treatment in Simple Melancholia 
(without Delusions). — A. S. E., young girl, aged 
eighteen, has suffered for the past few months from 
hysterical attacks, followed by periods of marked 
depression. She has neither hallucinations nor 
delusions, but she is irritable and obstinate, and at 
times difficult to control. Of late she has lost con- 
siderable flesh, her bowels are constipated, and, in 
fact, her whole physical condition is far from satis- 
factory. 

Recognizing the paramount necessity of improv- 
ing the general bodily state, I have had her drink 
warm milk, — often as much as four or five tum- 
blers a day; I have given her, in addition, both 
cathartics and diuretics ; and I have sought to have 
her take more air and exercise, at the same time 
endeavoring to promote sleep by the conservative 
exhibition of soporifics. 

These things have already begun to do good ; but, 
while she is more tractable and less inclined to cause 
worry to those about her, her attacks of depression, 
though perhaps not as frequent, are quite as severe 
as formerly. While suffering from one of these 
attacks of depression she was recently brought to 
my office by her mother; and, at my suggestion, 
she was placed in the air-chamber, a small dose of 

25* 



294 pain. 

the extract of absinthe and brandy having pre- 
viously been given her. 

In a short time the pressure was shown by the 
indicator to be fifteen pounds, and at this point it 
was maintained for twenty minutes or more. After 
the lapse of this period a marked change took place 
in the patient's appearance, as could readily be 
ascertained by looking through one of the large 
glass port-holes. Her face, which had previously 
worn a dejected, indifferent appearance, now dis- 
played a contented and even happy expression, and 
she occupied herself with reading the newspaper, 
— something that she had not done before for 
weeks. 

On leaving the air-chamber this air of content- 
ment remained, and, according to her mother's 
statement, she showed no further evidences of de- 
pression for the next three days. 

Though I had employed the above remedies, and 
various others as well (without the compressed air), 
on former occasions and in larger doses, it had never 
been my good fortune to obtain any appreciable 
immediate good from them. I feel, therefore, en- 
tirely convinced — more especially as I have since 
been able to produce the same class of effects over 
and over again, both in this and other patients — 
that the enhanced potency of the drugs was entirely 



THE SPECIAL THERAPEUTICS OF PAIN. 295 

due to the concomitant influence of the compressed 
air. 

Case V. A Case showing the Enhancement of the 
Soporific Powers of Hypnotics, and more especially of 
Chloralamid, by the Administration of the same while 
the Subject remains in a Highly- Condensed Atmosphere. 
— E. N"., a neurasthenic woman who has suffered 
from acute insomnia for several weeks, and who is 
inappreciably influenced by the usual hypnotics or 
their combinations, even when given in large doses. 

Among other soporifics I have given her chloral- 
amid in doses of forty-five grains, but with quite 
insignificant success ; for in spite of the remedy she 
declares that she never sleeps more than one hour 
or two out of the twenty-four. At my suggestion 
she consented to try the effects of the compressed- 
air treatment. 

Accordingly, I gave her a dose of thirty grains 
of choralamid, — fifteen grains less than she had 
previously taken at night; and fifteen or twenty 
minutes after its administration — the elastic straps 
having been previously adjusted to the lower extrem- 
ities, above the knees — she entered the air-chamber. 
The pressure was then raised to fifteen pounds to 
the square inch, as shown by the gauge ; and at this 
point it was maintained for upward of half an hour, 
the air being renewed from time to time, but without 



296 pain. 

altering the pressure. While thus exposed to the 
concomitant influence of the drug and condensed 
air she became drowsy, and finally fell asleep. 
From this state of unconsciousness she was only 
aroused by the noise of the escaping air as I 
opened the valve of the outlet-tube in order to 
empty the chamber. 

On the following day she stated that at the con- 
clusion of the treatment she had gone home, and, 
lying down upon the lounge, had immediately fallen 
asleep, only awaking after the lapse of five or six 
hours. In other words, she had slept the entire 
afternoon, — something that she was quite unable to 
accomplish even previous to the attack of insomnia. 

This case is instructive, as exhibiting the con- 
tinued good effects of this plan of treatment; by 
which I mean that the soporific tendency persists 
even after removal of the patient from the condensed 
atmosphere. I will merely add that this case went 
on to complete recovery, natural sleep supervening 
regularly, without artificial assistance of any kind, 
after treatment had been continued for four weeks. 

Case VI. Showing the Arrest of the Painful Crises 
of Locomotor Ataxia by the Compressed-Air Treatment. 
— One of the most effective applications of the com- 
pressed-air treatment is in the arrest of the periodic 
attacks of pain so characteristic of tabes dorsalis. 



THE SPECIAL THERAPEUTICS OF PAIN. 297 

A good illustration of this is afforded by a gentle- 
man who has been a sufferer from ataxia nearly five 
years, and who has been under my own observation 
more or less during the last three years. He ex- 
hibits the pupillary and sensory phenomena peculiar 
to the disease ; but the incoordination, though pro- 
nounced, does not as yet give rise to serious dis- 
turbance of locomotion. On the other hand, he 
suffers from periodic attacks of pain of great 
severity in both arms and legs, as well as about the 
chest ("girdling" pains). A crisis of this kind 
usually occurs about once in six or eight weeks, and 
lasts — if allowed to run its course — from thirty -six 
to forty-eight hours. For the purpose of mitigating 
these attacks he has invoked every species of medi- 
cation, including morphine, which he has had to 
abandon on account of marked idiosyncrasy. 

Recently, on the advice of the late Dr. Charcot, 
of Paris, he has taken antipyrin in large quantities, 
frequently, indeed, in doses of forty grains. It is 
true that these enormous doses of the drug con- 
trolled the pain ; but they accomplished this at the 
expense of the heart-beat, which suffered gradual 
but distinct impairment of vigor. 

Being desirous of reducing these monstrous doses, 
the detrimental influence of which on digestion and 
the heart's action he recognized, I proposed that 



298 pain. 

we should endeavor to reenforce the action of the 
analgesic by the aid of the compressed air. He 
consented immediately; and accordingly, on the 
next appearance of pains, a week or ten days later, 
he repaired to my consulting-room at once. 

Twenty grains of antipyrin — half the former dose 
— were then given him, combined with a drachm of 
the aromatic spirits of ammonia, and shortly after- 
wards he entered the air-chamber, where he re- 
mained for upward of an hour. During this time 
the air-pressure was maintained at two and a half 
atmospheres. After the lapse of twenty minutes 
he wrote on a piece of paper, which he displayed 
before the window of the chamber, that he was 
"feeling much better," and, fifteen minutes later, 
that the pains had disappeared. 

In fact, on leaving the chamber, twenty-five 
minutes later, he declared in the most emphatic 
manner that he was more relieved by the com- 
pressed-air treatment, with reduced doses, than by 
the enormous quantities (forty grains) of antipyrin 
which he had formerly been addicted to. Though 
the pains seemed to be completely aborted, — there 
being no return during the succeeding twenty-four 
hours, — he insisted, nevertheless, on taking the same 
treatment the following day, fearing, as he said, that 
the pain " might not forget to stay away." This 



THE SPECIAL THERAPEUTICS OF PAIN. 299 

precaution was perhaps not altogether superfluous, 
for, as has previously been said, the painful crisis 
generally persists thirty-six or forty-eight hours. 
Whether this second seance in the air-chamber was 
really necessary or not is, however, of little moment, 
the chief point of interest being that we were able 
to effectually abort the attack with a minimum of 
drugging. Another interesting feature is the fact 
that the next attack was much delayed in its appear- 
ance, three months having elapsed before the advent 
of the first darting pains. 

This, of course, may have been a coincidence 
only; and I was careful to so inform the patient, 
who seemed inclined to ascribe too much impor- 
tance to it. 

I must say, however, that this element of improve- 
ment continues ; for, since the first successful attempt 
to relieve him, he has always insisted on coming for 
the same purpose, as soon as the characteristic sen- 
sations are felt ; but the intervals between the attacks 
of pain are increasing in length. 

Since the publication of some of these cases in 
the Medical Record of August 29, 1891, I have 
treated over two hundred other cases, involving 
the use of the compressed air more than three thou- 
sand times. Though the pressure was occasionally 
carried up to three atmospheres, and generally to 



300 PAIN. 

two atmospheres, I have never had the slightest 
approach to an accident. This exemption from all 
unpleasant consequences I ascribe to two circum- 
stances : first of all, to the excellent ventilation ; 
and, secondly, to the invariable habit of allowing 
the air to escape quite gradually. As at present 
arranged, it is possible for the patient to let himself 
out of the air-chamber at any time, without external 
help of any kind. This fact tends, of course, to 
give him a feeling of perfect personal security, all 
that is required on his part being the simple opening 
of a valve inside the chamber, which in turn allows 
the escape of the air and the opening of the door, 
the latter being allowed to remain unfastened, the com- 
pressed air being itself sufficient to insure hermetical 
closure. 

All that has been said of compressed air in this 
chapter is confirmed, and more than confirmed, by 
the experience of those populations who are obliged, 
as in bridge- and tunnel-building, to work under 
unusual atmospheric pressures. So convinced are 
many of these persons by actual experience of the 
power of compressed air to augment the action of 
stimulants, that they vastly prefer to take their 
coffee and alcohol in the condensed atmosphere; 
and, in order to attain their end, they do not hesi- 
tate to conceal these articles in bottles and smuggle 



THE SPECIAL THERAPEUTICS OF PAIN. 301 

them into the delectable region, in spite of all rules 
to the contrary. I myself have seen the entire floor 
of extensive submarine workings covered with such 
bottles, and have had abundant occasion to hear 
from the lips of scores of workmen corroborative 
testimony as to this remarkable phenomenon. It 
was, indeed, the study of the habits and experiences 
of these submarine workers which led me to an 
appreciation of the importance of compressed air 
as a means of treating a variety of functional de- 
rangements of cerebro-spinal origin. 

Finally, certain definite effects are obtainable from 
compressed air without the concomitant assistance 
of remedies of any kind ; and to this circumstance 
some of the more permanent good derivable from 
this agent is possibly attributable. 

As space does not permit of pursuing the sub- 
ject further, I must refer those who are sufficiently 
interested to my original paper in the Medical 
Record, which has already been several times re- 
ferred to. 

Limitations of the Method. — Nothing in the 
world is more unwise than to claim too much for 
a new departure in therapeutics, however worthily 
conceived ; for the exaggeration at once overshadows 
the good in it, and the result is immediate con- 
demnation and the loss to science of what would 

26 



302 pain. 

have proven a valuable expedient had its field of 
legitimate action been accurately determined. 

This danger I am resolved to overcome by abso- 
lute openness of statement. 

In the first place, then, the compressed-air treat- 
ment, as previously described, is of no use whatever 
in the management of the inflammatory and degen- 
erative conditions of the spinal cord or its mem- 
branes. I have tried it in disseminated sclerosis, in 
spastic spinal paralysis, in poliomyelitis, with purely 
negative results. In cerebral hemiplegia its use is 
absolutely contraindicated ; and the same may be 
said of articular rheumatism, the pains of which 
are increased by air-pressure. Nor is neuritis a 
disease which lends itself to this mode of treatment, 
the increased pressure at the surface serving rather 
to augment than to diminish the pain. 

What, then, are the affections to which the com- 
pressed-air treatment, as previously described, is 
best adapted ? Speaking generally, it may be said 
that cerebral and cerebro-spinal difficulties of a 
functional character, in which pain, exhaustion, in- 
somnia, or depression are prominent features, are 
the most suited to this plan of treatment. Indeed, 
I have no hesitancy in saying that in the manage- 
ment of the last-named class of affections it is abso- 
lutely unapproachable. The cases already cited and 



THE SPECIAL THERAPEUTICS OF PAIN. 303 

commented upon, as well as the immutable physi- 
ology involved in the method, will, I trust, have 
carried conviction on this point. I would observe, 
however, that, did the space available permit, I could 
multiply the clinical evidence tenfold. 

In conclusion, let me add that not the least inter- 
esting influence of the compressed air is its ability 
to greatly enhance the effects of diuretics, a quality 
which is especially conspicuous in the case of coffee 
and diuretine. 



CHAPTER XVIII. 

REFLEX AND SPURIOUS OR IMAGINARY PAINS— HYPNOTISM. 

" Reflex" Pain. — "Within the last few years a great 
deal has been said and written regarding a class of 
pains which, while originating at the periphery, are 
referred to some other locality, and, notably, the 
central nervous system. The backaches which so 
frequently accompany uterine displacements, and 
the headaches consecutive to eye- strain, are instances 
in point. 

It is not always, however, an easy matter to decide 
whether a painful sensation is due to a local cause 
or is traceable to some distant source. This is espe- 
cially true of certain intracranial pains, the associa- 
tion or non-association of which with a local cause 
cannot be determined — if inspection were indeed 
of any value — on account of the inaccessibility of 
the parts. What, then, are the maxims to be ob- 
served when pain exists, in the absence of neuritis 
or other common cause, and when there is no 
evidence of autointoxication of any kind? The 
reasonable reply I believe to be this : Remove all 
304 



THE SPECIAL THERAPEUTICS OF PAIN. 305 

ascertainable causes of peripheral irritation, where 
the mutilation or danger to life is not great; for, 
even though the sequel may prove that the pain 
was not of reflex origin, it is certain that had the 
irritative element been allowed to remain its pres- 
ence would have interfered with and possibly en- 
tirely neutralized all our efforts to obtain relief in 
other ways. Let me again repeat, however, by way 
of qualification, that this is the logical course to 
pursue when neither the life of the patient nor 
extensive mutilation is concerned. Only pain of 
the greatest atrocity, which has resisted all other 
means to relieve it, and which is clearly the result 
of the peripheral difficulty, can justify measures in- 
volving great peril to life. 

But when we have said this we have sufficiently 
indicated the course which a reasonable conserva- 
tism may dictate; and we shall carefully abstain 
from wholesale condemnation of the efforts of 
gynaecologists, ophthalmologists, and other surgeons 
to render the removal of peripheral sources of irri- 
tation more certain ; for such condemnation, though 
originally in part justified by some very obvious 
exaggerations, has been carried to an extreme which 
is alike at variance with the facts and the canons of 
good taste. 

For my own part, I am free to confess that I 
u 26* 



306 pain. 

have long made it a practice to have all sources of 
peripheral irritation eliminated, as far as possible, 
in those who come under my care for pain, or, 
indeed, for any kind of nervous trouble. My expe- 
rience has, in fact, taught me that such peripheral 
disturbances — though they may not always be, and, 
indeed, frequently enough are not, the real source 
of the trouble — possess the quality of interfering 
with, and even absolutely neutralizing, everything 
that may otherwise be done for the patient. 

This applies in an exceptional degree to anomalies 
of refraction, which are often the source, and, if not 
the source, then the perpetuating factor of various 
head-pains. Dr. David Webster has lately written 
with great lucidity and conservatism on this point. 

Spurious or Imaginary Pains. — When a person 
has long been the victim of more or less continuous 
pain of either a local or general character, but more 
especially the former, it inevitably follows that the 
mind gradually assumes an anticipatory attitude 
towards the unpleasant feeling ; so that, even when 
the latter is temporarily absent, the " concept" pain 
still haunts the mind, and the patient believes that 
he suffers. The foundation of these delusions is 
substantially that of the analogous phenomena ex- 
hibited by hypnotism, — to wit, expectant attention 
awakened by the continual repetition of the un- 



THE SPECIAL THERAPEUTICS OF PAIN. 307 

pleasant sensation. Hysterical and imaginative 
persons are especially prone to become victims of 
this subjective kind of pain; and it is interesting to 
note that they are likewise amenable to hypnotic 
influence. While it is of importance, as may readily 
be imagined, to determine, in a given case, whether 
the pains be really objective or purely of subjective 
origin, it must not be forgotten that, in so far as 
the sufferings of the individual are concerned, one 
variety is about as bad as the other. Hence violent 
and mandatory conduct on the part of the physician 
is to be discouraged, as being both unscientific and 
inhuman. 

Powerful moral influence, coupled with adroit 
suggestions of an opposing character, — the attention 
of the subject being meanwhile directed away from 
the imaginary seat of pain, — will be found to yield 
the best results. All this can generally be accom- 
plished while the patient remains in his usual 
waking condition, and without invoking the aid of 
hypnotism, the induction of which is often beset 
with great difficulty, and is, in a considerable per- 
centage of cases, quite impossible. Concerning the 
dangers of hypnotism, as well as the therapeutic 
uses to which this agent might possibly be put, I 
have expressed some opinions which, though rather 
pessimistic, are, I believe, strictly in accordance with 



308 pain. 

the facts. 1 The following observations are taken 
from m y original paper : 

Possible Dangers of Hypnotism. — As long ago 
as 1784 some of the dangers of hypnotism were 
pointed out by De Puysegur, a pupil of Mesmer. 
The danger to which he referred more particularly 
was the criminal use which an unprincipled person 
might make of the ascendency gained over the sub- 
ject. These warnings, frequently repeated of late, 
are not without reason, as the annals of crimes 
committed during the last sixty years abundantly 
prove. Rape, kidnapping, and murder are some of 
the crimes charged to the account of the nefarious 
hypnotizer. 

But these are not the only sources of danger ; for 
experience has abundantly shown that the subject 
himself may be prompted to commit theft and other 
species of crime after emerging from the hypnotic 
condition. This fact, which has already been men- 
tioned, has become the subject of special judicial 
enactment in several countries. 

Finally, the repeated hypnotization of the subject 
is liable to be followed by more or less dangerous 
consequences. Inordinate emotionality, impairment 

1 " Some Practical Considerations on the Nature and Induction 
of the Hypnotic State," the Medical Kecord of November 8, 1890. 



THE SPECIAL THERAPEUTICS OF PAIN. 309 

of volition, and a tendency to become spontaneously 
hypnotized, or, at least, excessively drowsy, are some 
of the more obvious features of this post-hypnotic 
condition. I have at the present time under my 
care a gentleman who exhibits this neurosis — for 
neurosis it certainly is — in a striking manner. He 
is a man of rare gifts : he has maintained, and still 
enjoys, a high position in the community; and yet 
his mental decrepitude is so obvious that it is matter 
of astonishment to me that he has been able to 
disguise its source so long. Currently, he is re- 
garded as a sufferer from mental overwork, and I 
must confess that I should have had great difficulty 
in arriving at the true nature of his difficulties had 
he not confessed that he had been hypnotized scores 
of times, and that his present infirmity had come on 
as the direct result of these abuses, — for abuses they 
certainly were. 

Such a person as this is exposed to manifold 
dangers, for he has become so susceptible that not 
only is it possible for any one to hypnotize him, but 
he is able, without further assistance, to induce in 
himself the sleep-like state. 

These, then, are the more manifest dangers of 
hypnotism. 

Concerning possible Therapeutic Uses of Hyp- 
notism. — I am not very sanguine as to the future 



310 PAIN. 

of hypnotism as a curative agent in nervous or 
other diseases. According to my own researches, — 
and those researches date back eight years or more, 
— the method is vastly more limited than one would 
imagine from the exaggerated claims which have 
been of late advanced in its behalf by over-zealous 
medical men. Let me mention a few of those lim- 
itations. In the first place, only a certain (unknown) 
percentage of persons are amenable to the hypnotic 
influence; or, to express it more exactly, only a 
limited number of persons are hypnotizable with 
the present means at our command. Secondly, the 
effects obtainable are evanescent; for, unless we 
hypnotize the patient so often as to incur the risk 
of doing him an injury, we cannot hope to per- 
petuate the suggestions sufficiently to do any good. 

From these considerations it follows that the per- 
manent effects which one may hope to produce upon 
the material economy through this class of psychical 
forces must be insignificant. Functions may, it is 
true, be exalted or depressed for the time being, but 
qualitative changes in the structures themselves are 
impossible. The internal capsule, the thalamus, the 
motor convolutions, the sensory tracts in the cord 
once destroyed are not to be restored by any form 
of interference. Moreover, a physiological substitu- 
tion (in Bernheim's sense) for these and analogous 



THE SPECIAL THERAPEUTICS OF PAIN. 311 

structures seems well beyond the farthest bounds of 
physiological probability. Hence, as I have pre- 
viously mentioned, all attempts to apply hypnotism 
to the treatment of organic disease are opposed to 
sound thinking. Indeed, I regard such proposals as 
hurtful to science, and particularly medical science, 
inasmuch as the reputation of the profession for 
sound judgment is thereby greatly jeopardized. 
The facts which the advocates of such questionable 
methods have to present are still too few in number, 
and too meagrely substantiated, to form the basis of 
affirmative argument. What, then, is the position 
which hypnotism may be expected to assume in the 
neuro-therapy of the future ? In my opinion, the 
rdle which it is destined to play is a subordinate one. 
In the light of its present and past history I do not 
see how it can be otherwise. As an adjunct in the 
management of minor degrees of hypochondria, 
morbid apprehension, depression, and hysteria, it 
may sometimes be invoked, but then only as a col- 
lateral expedient, and largely with a view to render- 
ing the patient more tractable and amenable to other 
elements in the plan of treatment. The assistance 
afforded by an appeal to the expectancy of the sick 
is familiar to every physician. By invoking the aid 
of the hypnotic state such an appeal may be made 
with an energy which is not attainable while the 



312 



PAIN. 



patient remains in the ordinary mental condition. 
But, while the miracles recorded by enthusiastic 
writers make, like Munchausen's tales, entertaining 
reading, they are not likely to enter into the sober 
realities of the consulting-room. 

In view of what we now know of it, hypnotism 
is to be dealt with by the physician ; for it is evident 
that a competent medical man is alone in a position 
to judge of its real or imaginary advantages. Cer- 
tainly, only such a man should be allowed by our 
statutes to invoke its assistance in the treatment of 
diseases, however insignificant. 



CHAPTER XIX. 

CONCLUDING OBSERVATIONS ON THE PREVENTION OF RE- 
LAPSE — THE PROPHYLAXIS OF PAIN. 

A very large proportion of pains exhibit a ten- 
dency to return. We must, therefore, do everything 
in our power to antagonize this baneful propensity, 
by interrupting the periodicity of the attack, and 
by continuing to employ such agents as experience 
has shown us to be useful in perpetuating the good 
already obtained. Some of the remedies previously 
mentioned, and, notably, quinine, iron, arsenic, aco- 
nitia, and cannabis indica, are very useful for this 
purpose. It is, indeed, necessary to do something 
more than to interrupt the paroxysm, though this 
of itself tends to permanent good by breaking up 
the painful habit ; but, in addition, we must examine 
each case thoroughly, neglecting nothing in the 
history of the case which may possibly serve to 
enlighten us regarding the true origin of the pain. 
Sometimes we shall be able to trace the painful 
manifestations to some organic disorder; under 
these circumstances we may profitably invoke the 
o 27 313 



314 pain. 

aid of general medicine. In other cases the pain 
is manifestly due to nerve-injury or some other 
accident, and we may then have recourse to sur- 
gery. 

In by far the greater number of cases, however, 
we are able to trace the pain to neither injury nor 
organic disease; but, if we examine such cases 
attentively as to the state of the general health, we 
are usually able to discover some qualitative or 
quantitative change of nutrition of sufficient gravity 
to account for the phenomenon. It is, indeed, self- 
evident that where these derangements of nutrition 
exist such a complicated structure as the nervous 
system must inevitably deteriorate; and, as the 
whole history of neuritis shows, the peripheral 
nerves are especially liable to suffer. Sometimes 
the vitiated condition of the system is traceable to 
malarial poisoning; sometimes to syphilis; some- 
times to gout; and sometimes, doubtless, to some 
form of autointoxication with which we are still 
unacquainted. Whatever the cause of the debility 
may chance to be, it should be removed as speedily 
as possible. Sometimes the pain disappears as soon 
as the general condition of the patient begins to 
improve ; in other cases, supplementary measures — 
which have for their object the elimination of the 
propensity to return, so common to most forms of 



THE SPECIAL THEEAPEUTICS OF PAIN. 815 

pain — must be adopted. The latter phase of the 
subject has already been sufficiently discussed. 

But not all debilitated persons are necessarily the 
victims of obstinate pain, as every physician is fully 
aware. Certain extraneous circumstances, certain 
phases of environment, are required, in order that 
malnutrition shall express itself in pain. 

Among such external circumstances may be men- 
tioned intense cold, with moisture, and sudden 
changes in temperature. These are the things 
which must be borne by those who, in the regular 
course of their daily vocations, are obliged to go 
from hot apartments into the cold, external atmos- 
phere ; or who are compelled to live in a climate of 
sudden changes, which really amounts to the same 
thing. Against circumstances of this kind it is, of 
course, impossible to provide an absolute remedy. 
We may counsel frequent changes of clothing to 
suit the fluctuations of temperature ; we may advise 
that persons who go from hot to cold apartments, 
in the pursuit of their daily duties, shall make such 
transitions as gradually as possible ; we may do this 
and more, and yet find that our injunctions are 
not of much avail, in so far as the attainment of 
permanent good is concerned. 

Such being the unfortunate situation, one is often 
at a loss what to recommend. Sometimes I have 



316 PAIN. 

advised persons thus exposed to dress in thick 
woollen garments, — those next the skin being spe- 
cially made with a view to facilitating the absorp- 
tion of the cutaneous secretions; and over these 
conventional garments I have the patients wear a 
perforated vest of thick paper, lined with silk. 

As a matter of course, great attention should be 
paid to all matters of diet. The patient should be 
put upon nutritious food, which at the same time 
must be digestible. Beefsteaks, mutton-chops, milk, 
cod-liver oil, and eggs are the staples where the 
aneemia is pronounced. Should the powers of as- 
similation be impaired, we must then resort to a 
good preparation of malt. I prefer that of Trom- 
mer, which acts upon starch with great energy, as 
every physician can ascertain by applying the iodine 
test. Pepsin and acids may, of course, be given 
when indicated. As a matter of course, red meats 
are to be avoided in rheumatic cases. 

These, then, are the principles to be observed in 
the management of pain. As may well be imagined, 
the intricacy of the whole subject of pain is such, 
and its connection with a vast array of pathological 
conditions so intimate, that it is impossible to do 
more than formulate general rules for its manage- 
ment. Many cases will necessitate much tact in 
overcoming complicating circumstances of various 



THE SPECIAL THEEAPEUTICS OF PAIN. 317 

kinds. These I shall not attempt to discuss here, 
as they properly belong in the domain of general 
medicine or surgery. 

If, however, I have succeeded in indicating prin- 
ciples of general utility, I shall be content. But if, 
in addition, I shall have been able to abate some- 
what the use of enslaving drugs, I shall also feel 
that the ethical value of the work has been pro- 
portionately enhanced. 



CHAPTEE XX. 

SUPPLEMENTARY OBSERVATIONS ON TORTURE, OR THE IN- 
FLICTION OF PAIN AS A JUDICIAL PUNISHMENT OR FOR 
THE PURPOSE OF EXTORTING A CONFESSION OF GUILT. 

There is no chapter in the history of the human 
race so well calculated to cause a blush of shame as 
that which deals with torture. 

That creatures with any discernible resemblance 
to men could have been found to conceive and exe- 
cute such abominations; that society should have 
tolerated them; that the learned classes, or what 
passed for such, should not only have condoned the 
infamy, but actually invoked it, is an enigma before 
which even the astute psychologist stands aghast. 

Whatever may be said of the corruption of civil 
and ecclesiastical government, which is such an 
apparent feature of the Dark Ages, this of itself is 
not sufficient to account for the systematized cruelty 
which found expression in the thumb-screw, the 
rack, and the fagot. The true cause of such moral 
obliquity is rather to be sought for in the unutter- 
able ignorance, superstition, and moral debasement 
of the whole population, which alone made possible 
318 



THE SPECIAL THERAPEUTICS OF PAIN. 319 

the tyrannies of the feudal and ecclesiastical author- 
ities throughout Europe. That the degradation of 
the common people was the real source of this or- 
ganized brutality is shown by the fact that even 
in the republic of Switzerland, under a relatively 
liberal form of government, torture was a recog- 
nized element of ecclesiastical and judicial disci- 
pline. It was, moreover, precisely in such a soil as 
this that retributive ideas of justice, as opposed to 
the reformatory principles of modern criminology, 
were certain to nourish. As a result of this uni- 
versal intellectual and moral debasement it was 
possible for both the civil and ecclesiastical powers 
to enforce their authority by incredible cruelty, and 
without fear of a popular uprising. 

R~o revolutionary movement could, indeed, have 
succeeded, even had a portion of the population 
been disposed to throw off the yoke of despotism, 
since persons competent to lead such a movement 
were only to be found among the privileged classes, 
whose interests were bound up with existing insti- 
tutions. The league of the civil authorities with 
the Church would, moreover, have rendered such an 
attempt abortive from the start, since the supersti- 
tion of the peasantry rendered them abject slaves 
to the ecclesiastical power. In a word, it is only 
through the percolation of enlightened sentiment 



320 pain. 

among the masses of the people that one may hope 
to antagonize that fundamental predisposition to 
cruelty which is the birth-mark of animalism. The 
self-inflicted tortures of Oriental and European as- 
cetics are but extreme manifestations of the belief 
in the retributive character of punishment. Even 
iu our own day the great reforms in prison disci- 
pline, and the humane instincts which actuate the 
most enlightened persons, have not sufficed to elim- 
inate from the minds of the ignorant the conception 
of revenge as an essential feature of judicial penal- 
ties. The conceptions which such persons entertain 
of the Deity are also colored by their brutish in- 
stincts ; and, what is still more to be regretted, they 
have been able to foist their crude and barbarous 
conceptions upon persons who are infinitely their 
superiors in the scale of moral and intellectual 
enlightenment. 

In 1640 occurred the last-recorded instance of 
judicial torture in England; but there is reason to 
believe that it was often secretly applied long after- 
wards. However this may be, it is certain that the 
revolting practice was in vogue both in France and 
Germany long subsequent to its official abolition in 
Great Britain. But even in the Irish dependencies 
of the latter country there was a sporadic revival of 
torture by the military judges in 1798. 



THE SPECIAL THERAPEUTICS OF PAIN. 321 

As a means of extorting a confession it was com- 
monly resorted to in various parts of Europe till 
the close of the last century. This seems incredi- 
ble ; but the fact is adequately attested. 

It may readily be imagined that cries of protest 
were not lacking in the midst of this systematized 
barbarity; in fact, some of the most eminent men 
of the day were loud in their denunciations. Among 
those who gave vent to their disapproval were Bec- 
caria and Voltaire ; and to their endeavors the final 
disappearance of torture from Europe was largely 
due. 

The following are some of the more common 
modes of inflicting torture, prevalent throughout 
the continental countries during the Dark Ages : 

Pouring boiling oil or molten lead on various 
portions of the body by the aid of a perforated spoon 
or sieve. Flagellation with scourges of barbed iron, 
so that the flesh was extensively lacerated. Tearing 
the tongue out, a penalty for blasphemy. Stretch- 
ing the victim on a species of couch and flaying 
him alive. Crushing the thumbs, toes, feet, hands, 
or shinbone by the aid of vice-like arrangements 
constructed with diabolical ingenuity. Suspected 
persons were made to submit in all European 
countries to the ordeal of the thumb-screw; and 
so fearful was the torture endured that the victim 



322 pain. 

frequently implicated himself and others by forced 
confessions of crimes of which all were entirely 
innocent. Breaking on the wheel, and burning to 
death, — the latter penalty being at one time ex- 
ceedingly common in Europe. Among the chief 
victims were poor old women accused of witchcraft. 
Stretching the victim on the rack and pouring 
boiling oil or molten lead down his throat was 
also a common mode of judicial punishment. 

These awful details of a nightmare of cruelty, 
which held all Europe in Satanic bondage for 
several centuries, are at once a warning against 
the dangers of primitive animalism, and an appeal 
to the spirituality and altruism which inevitably 
flow from the highest knowledge. 

It should be a source of congratulation to all 
medical men to know that the physicians of the 
Middle Ages — or those who passed for such — usu- 
ally did what they could to mitigate the sufferings 
of those of their unfortunate fellow-beings who 
were condemned to inquisitorial pain. 

These, I believe, are the principal sources of the 
barbarity which pervaded all Europe during the 
Dark Ages, — a barbarity which found a most awful 
expression in tortures, the devilish ingenuity and 
cruelty of which seem incredible in the light of 
modern meliorism. 



INDEX. 



Alcoholic intoxication, neuritis in, 48. 
Angina pectoris, 87. 

due to organic disease of the heart, 88. 
idiopathic form of, 88. 
symptoms of, 89. 
treatment of, 89. 
Beriberi, neuritis in, 56. 

Calabar bean, action of, opposed to that of strychnine, 186. 
Cerebral cortex, sensory regions of, 18. 
Cold in the treatment of pain, 225. 

Compressed air, author's method of employing it as an adjunct in 
the treatment of pain of cerebro-spinal origin, 256. 
as a means of focalizing the effect of remedies upon the 

intracranial structures, 275. 
illustrative cases, 287. 
limitations of the method, 301. 
Counter-irritation in the treatment of pain, 225. 
Electricity in pain, 223. 
Gout, 71. 

a prolific source of pain, 70. 
mineral waters in, 77. 
theories regarding the nature of, 71. 
treatment of, 76. 
Headache, 81. 
anaemic, 81. 
bilious, 83. 
cerebro-anaemic, 82. 
cerebro-hyperaemic, 82. 

323 



324 INDEX. 

Headache, hyperamiic, 82. 

nervous, 82. 

neurasthenic, 83. 

organic, 85. 

toxic, 84. 
Heat in the treatment of pain, 225. 
Hypnotism, possible utility of, in pain, 309. 
Influenza, neuritis in, 50. 
Insomnia as a complication of pain, 128. 
Leprosy, neuritis in, 51. 
Melancholia as a complication of pain, 134. 

compressed air and stimulants in, 161. 

shower-baths in, 164. 
Mineral waters in gout, 77. 
Nerves, sensory and motor, 22. 

Du Bois Eeymond's experimental researches regarding, 23. 

evolution of electricity in, 23. 

identity of processes in, 22. 

Kadcliffe on, 22. 
Neuralgia, 62. 

cardiac, 87. 

cervico-brachial, 67. 

cervico-occipital, 67. 

coccygodynia, 68. 

crural, 67. 

dorso-intercostal, 68. 

general symptomatology of, 63. 

intercostal, " mastodynia, " 68. 

lumbar, 67. 

lumbo-abdominal, 68. 

muscular, 69. 

prognosis of, 69. 

sciatic, 68. 

trigeminal, 66. 
Neuritis, 29. 

alcoholic, 48. 

differentiation of, from ataxia, 50. 
symptoms of, 48. 

" beriberi" as a factor of, 57. 



INDEX. 325 

Neuritis, general considerations on, 29. 

influenza (" grippe") as a cause of, 50. 

Gowers on, 51. 
leprosy as a cause of, 51. 

Leloir on, 51. 

Morrow on, 53. 
multiple, 41. 

cause of death in, 47. 

diagnosis of, 60. 

functions of bladder and rectum in, 48. 

prognosis of, 61. 

symptoms (general) of, 44. 

tendon reflexes in, 48. 
simple, 31. 

pathology of, 36. 

prognosis of, 35. 

symptoms of, 32. 

treatment of, 40. 
Pain, appearances at the seat of, 109. 

cardiac derangements in ; Franck and Potain on, 111. 
definition of, 11. 

Bilon on, 11. 

Cicero on, 11. 

Corning on, 12. 

Erb on, 12. 

Eulenburg on, 12. 

Gaubius on, 11. 

Sauvage on, 11. 

Valentin on, 12. 

Wundt on, 12. 
derangements of motility in, 111. 
diagnostic value of, 92. 

in diseases of the organs within the thorax, 98. 

in organic diseases of the nervous system, 102. 

when located in the head, eye, and ear, 94. 
diminution of the secretory and excretory functions in, 112. 
disorders of nutrition in, 112. 
facial expression in 110. 
immediate death from, 113. 

28 



326 INDEX. 

Pain, infliction of, as a judicial punishment, 318. 
insomnia in, 128. 
intra-abdominal, 91. 
intracranial (headache), 81. 
intra-thoracic, 87. 

location of, in definite nerve-areas, 62. 
loss of appetite in, 112. 
medico-legal significance of, 108, 117. 
melancholia in, 134. 
nervous irritability in, 109. 

objective method of determining the presence of, 113. 
perception of, not confined to an isolated cortical area, 14. 
prevention of relapse in, 313. 
prophylaxis of, 314. 
reflex, author on, 304. 
spurious, 306. 

in hysteria, 113. 
suicide in, 137. 
therapeutics of, 140. 

aconitia in, 226. 

acupuncture in, 225. 

alcohol in, 168. 

antipyrin in, 189. 

arsenic in, 188. 

baths in, 77. 

belladonna in, 181. 

bromides in, 174. 

by local medication of the spinal cord (author's method), 
241. 

by medication of the cauda equina (author's method), 247. 

by "suspension," 254. 

cannabis Indica in, 178. 

chlorodyne in, 173. 

chloroform in, 173. 

cocaine in, 197. 

cold in, 225. 

compressed air with analgesics in (author's method), 256. 

counter-irritation in, 225. 

electricity in, 223. 



INDEX. 327 

Pain, therapeutics of, ether in, 173. 
exalgin in, 192. 
gelsemiuni in, 177. 
heat in, 225. 
helleborein in, 197. 
Hoffmann's anodyne in, 173. 
hydrobromic acid in, 176. 
hypnotism in, 309. 
iodopyrin in, 196. 
kava-kava in, 197. 
methacetine in, 197. 
methoxy-caffeine in, 197. 
methylene blue in, 196. 
napelline in, 196. 
ointments in, 226. 
opium in, 166. 
para-acetophenetidin in, 1 96. 
phenacetin in, 190. 
phenocoll in, 195. 
pressure in, 224. 
quinine in, 187. 
rest in, 141. 
salipyrin in, 193. 
salol in, 192. 
salophen in, 194. 
solanine in, 194. 
strychnine in, 186. 
thrombosis, therapeutic in, 216. 
thymacetin in, 195. 
urethane in, 195. 
veratrine in, 226. 
zinc in, 187. 
surgical therapeutics of, 227. 

Abbe on the surgical treatment of inveterate tic douloureux 

in, 228. 
Carnochan on resection of the affected nerve in, 228. 
Dennis on the resection of nerves in, 231. 
division of sensory nerve-roots in, 231. 
ligation of arteries in, 228. 



328 INDEX. 

Pain, surgical therapeutics of, resection of semilunar ganglion for 
inveterate facial neuralgia in, Rose and Andrews on, 233. 
vaso-motor anomalies in, 112. 
Painful impressions, transmission of, 16. 

correct and erroneous reference of, 25. 
through the cord, 17. 
through internal capsule, 18. 
through the peripheral nerves, 16. 
Pressure in the treatment of pain, 224. 
Reflex pain, author on, 304. 

Remedies, enhancement of their effects upon the peripheral nerves 
(author's methods), 206, 213, 216. 
internal, applicable in the treatment of pain or its complica- 
tions, 165, 189. 
introduction of, into the skin by the aid of the galvanic cur- 
rent, 209. 
laws regarding the action of, on the nervous system, 198. 
local analgesic, 197. 

recent, which have been employed in the treatment of pain, 189. 
sedative, 165. 
stimulating, 177. 
surgical, in pain, 227. 
Rest, cerebral, author's plan of, 151. 
Rheumatism, 70. 

a prolific source of pain, 70. 
Satterlee on, 79. 

theories regarding the nature of, 70. 
treatment of, 74. 
Sensorium, isolation of, from environment (author's plan), 154. 
Spinal concussion, 117. 

illustrative cases of, 120. 
symptoms of, 118. 
Spinal irritation, 186. 

strychnine in, 186. 
Therapeutic thrombosis, author's method of inducing, 216. 
Torture, or the infliction of pain as a judicial punishment, 318. 



THE END. 



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